• A/California/7/2009 (H1N1)-like (the same strain as was used for 2009 H1N1 monovalent vaccines)
• A/Perth/16/2009 (H3N2)-like
• B/Brisbane/60/2008-like antigens be used.

• Vaccination efforts should be structured to ensure the vaccination of as many persons as possible over the course of several months, with emphasis on vaccinating before influenza activity in the community begins. 
• Health-care providers should begin offering vaccination soon after vaccine becomes available and if possible by October

• Two doses if receiving a seasonal influenza vaccine for the first time
• Two doses if the child received only one dose of  seasonal vaccine for the first time during 2009-2010
• Two doses if the child did not receive at least one dose of influenza A (H1N1) 2009 monovalent vaccine, regardless of previous influenza vaccination history
• Two doses if the previous 2009--10 seasonal or influenza A (H1N1) 2009 monovalent vaccine history cannot be determined
• For all children, the second dose of a recommended 2-dose series should be administered ≥4 weeks after the initial dose.

• LAIV concurrently with MMR alone and MMR and varicella vaccine among children aged 12-15 months.
• Inactivated or live vaccines (MMR alone and MMR and varicella vaccine) can be administered simultaneously with LAIV. After administration of a live vaccine, at least 4 weeks should pass before another live vaccine is administered.

• TIV can be given to persons receiving influenza antiviral for treatment or chemoprophylaxis.
• LAIV should NOT be administered until 48 hours after cessation of influenza antiviral therapy.

• As a precaution, persons who are not at high risk for severe influenza complications and who are known to have experienced GBS within 6 weeks of receipt of an influenza vaccine generally should not be vaccinated.
• As an alternative, physicians might consider using influenza antiviral chemoprophylaxis for these persons.
• The established benefits of influenza vaccination might outweigh the risks for many persons who have a history of GBS and who also are at high risk for severe complications from influenza.

• LAIV can be administered to persons with minor acute illnesses (e.g., diarrhea or mild upper respiratory tract infection with or without fever).
• If nasal congestion is present that might impede delivery of the vaccine to the nasopharyngeal mucosa, use of TIV, or deferral of administration should be considered until resolution of the illness, is recommended.
• Development of GBS within 6 weeks following a previous dose of influenza vaccine.
• Note: persons who are NOT at high risk for severe influenza complications generally should not be vaccinated

• Persons with a history of hypersensitivity, including anaphylaxis, to any of the components of LAIV or to eggs;
• Children aged <2 years;
• Children aged 2-4 years whose parents or caregivers report that a health-care provider has told them during the preceding 12 months that their child had wheezing or asthma or whose medical record indicates a wheezing episode has occurred during the preceding 12 months;
• Persons with asthma;
• Persons aged ≥50 years;
• Adults and children who have chronic pulmonary, cardiovascular (except isolated hypertension), renal, hepatic, neurologic/neuromuscular, hematologic, or metabolic disorders;
• Adults and children who have immunosuppression (including immunosuppression caused by medications or by HIV);
• Children or adolescents aged 6 months--18 years receiving aspirin or other salicylates (because of the association of Reye syndrome with wild-type influenza virus infection);
• Pregnant women;
• Any person who is a close contacts of an immunosuppressed person who requires a protected environment.

• Who may administer LAIV:
• Healthy persons
• Other persons at higher risk for influenza complications (persons with underlying medical conditions placing them at higher risk or who are likely to be at risk, including pregnant women, persons with asthma, and persons aged ≥50 years) who are not immunosuppressed.Who should NOT administer LAIV:
• Who should NOT administer LAIV:
• Severely immunosuppressed persons should not administer LAIV.

• Moderate or severe acute illness with or without fever until symptoms have abated;
• Development of GBS within 6 weeks following a previous dose of influenza vaccine.
• Note: persons who are NOT at high risk for severe influenza complications generally should not be vaccinated

• Persons known to have anaphylactic hypersensitivity to eggs or to other components of the influenza vaccine unless the recipient has been desensitized.
• Information about vaccine components is located in package inserts from each manufacturer.

• Prior to initiating any medication for LTBI, check to see if your patient is taking other medications that would potentially cause a drug-drug interaction.

• Instruct your families to report any side effects from medications immediately. I always let patients know that body fluids may appear orange while taking rifampin and that rifampin may stain contact lenses.

• Patient monitoring should include:  monthly physician visits for a physical examination, assessment of medication adherence, and reviewing for adverse drug reactions.

• Laboratory monitoring is indicated in patients with a history of HIV, hepatic disease, and pregnancy (or within 3 months post delivery).

Offit, PA et al. Pediatrics 109(1) Jan 2002

Infants may be susceptible to measles infection earlier than once thought. The first dose of measles vaccine is 12-15 months of age. Infants rely on protection through transplacental passage of maternal antibody and herd immunity within a community. One US study reported that 11% of children had a delay in vaccination for six to 8 months during their first two years of life. We have seen how infants are at increased risk for infection (recent measles outbreak in California). 

The current study published in the British Medical Journal describes early susceptibility to measles in infants of both vaccinated women and women with naturally acquired immunity.  There were two groups of woman-infant pairs: a vaccinated group (87) and a naturally immune group (120).  Measles IgG antibodies were measured at seven different times over a 12 month period beginning at 36 weeks gestation.  The infants born to vaccinated mothers had significantly lower geometric mean titers than did infants born to naturally immune women.  The median time to loss of immunity was 2.6 months (0.97 months for infant of vaccinated mothers and 3.78 months for infants of naturally immune women). At six months of age, 99% of infants of vaccinated women and 95% of infants of naturally immune women had lost maternal measles antibody. This would leave a window of >6 months for an infant to be vulnerable to infection with measles. If we continue to see the re-emergence of measles within the United States, the number of cases in infants will increase.  This study further emphasizes the importance of timely immunization and keeping high levels of immunity within a population to protect those vulnerable that do not have an opportunity to be vaccinated.

California is experiencing the worst pertussis epidemic in 50 years. As of June 30, 2010 California has seen a 418% increase in the number of pertussis cases reported to the California Department of Public Health (CDPH). Sources of infection continue to be household contacts. 

Recently a young infant died of pertussis at All Children's Hospital. California has reported 7 infant deaths this year so far. This information can be used when discussing the utility of vaccines with parents who are more concerned about vaccine safety than illness morbidity and mortality.

Disease is severe and can be fatal in infants. Infants that survive have significant morbidity, including admission to the intensive care unit with respiratory failure. In some instances infants have required ECMO (extracorporeal membrane oxygenation).

Bordatella pertussis is the cause of "whooping cough", a disease which typically begins with mild upper respiratory tract symptoms (catarrhal stage) and then progresses to a severe cough, often with inspiratory "whoop" and post-tussive emesis (paroxysmal stage). The disease abates very slowly, often over several weeks (convalescent phase). It is most severe in infants, often causing periods of apnea, and seizures. Most all of the fatal cases are in infants under 6 months of age. Almost all of these cases are complicated by hyperleukocytosis and pulmonary hypertension.

Pertussis is diagnosed by culture or PCR from a nasopharyngeal sample. Serologic testing has no role in the diagnosis of acute pertussis in young infants. Marked lymphocytosis and leukocytosis occur often, but are not always seen.

All infants with suspected pertussis should be treated with 10mg/kg of azithromycin for 5 days. Therapy should be started empirically (before laboratory confirmation of illness) in all infants with suspected disease. Infants under 3 months old should be hospitalized for pertussis, as the severity of the illness is often unpredictable.

Most cases of infantile pertussis are transmitted via close family contacts including parents and older siblings, many of whom are unaware of their diagnosis. CDPH is increasing its efforts in trying to prevent pertussis transmission to young infants by offering free Tdap vaccine to birthing hospitals and local health departments and encouraging their use for vaccinating the family members and caregivers of young infants. Tdap is recommended for post-partum mothers who have not yet had a Tdap vaccine and for whom it has been > 2 years since their last Td vaccine.

Healthcare workers should receive the Tdap vaccine. However, those of us who get the vaccine and subsequently are exposed to a child with pertussis still need to take a prophylactic antibiotic since the vaccine only has about 85% efficacy. In a recent abstract presented at the International Conference on Healthcare-associated Infections in Atlanta, vaccinated healthcare personnel who were exposed to a child with pertussis were significantly more likely to develop symptomatic infection if they did not receive prophylaxis (16.7%) than those who did receive prophylaxis (2.9%).

Goins WP, et al. 5^th Decennial Intl Conference on healthcare-associated infections, March 18-22, 2010.

Shea.confex.com/shea/2010/webprogram/Paper2298.html

On a related subject, the old whole-cell pertussis vaccine was associated with an increased seizure incidence (within 3 days of a vaccine dose) of 1 case per 1750 doses administered. A new study shows that the acellular pertussis vaccine was not associated with an increased seizure rate among  433,654 children in California.

Huang WT, et al. Pediatrics 2010;126:e263-9.

www.pediatrics.org/cgi/doi/10.1542/peds.2009-1496

We all have the dilemma of children presenting with lymphadenitis that we suspect may be secondary to mycobacteria. The critical issue becomes is this tuberculous (TB)or nontuberculous (NTM). Are there any factors that we could use to distinguish the two? Why is this important? The management is drastically different between the two. A retrospective study was done in Italy that reviewed medical records from a 10 year period of children <16 years of age with the final clinical diagnosis of mycobacterial lymphadenitis. 31% of the cases had tuberculous cervical lymphadenitis and 69% had nontuberculous lymphadenitis.  History of contact with a known TB case was reported in 5% of the tuberculous adenitis cases and in none of the nontuberculous cases.  Children with TB lymphadenitis were older and had more frequent abnormal chest radiograph findings but this was not statistically significant compared to the nontuberculous lymphadenitis group.  56% TB cervical adentitis patients had an abnormal chest xray mainly with mediastinal lymph node enlargement compared with only 8.5% among children with NTM cervical adenitis.  TST of >=10mm induration occurred for all children with TB adenitis but on 47% with NTM adenitis.

Using a model to predict the diagnosis of TB lymphadentis:

5 y/o foreign born child with cervical adenitis and an abnormal xray would have a 90% chance of a TB diagnosis whereas a 5 y/o child born in Italy with cervical adenitis with a normal chest xray would have a 4% chance of TB diagnosis. This model has 87.5% sensitivity and 88% specificity.

PIDJ 2010;29:629-633

When we think of petechial rashes in infectious disease three things usually come to mind including: meningococcemia, rickettsial disease, and enterovirus infections. However, a recent article in Pediatrics described 13 of 17 children with confirmed parvovirus B19 infection presenting with a mild febrile illness and petechial rash. The trunk and extremities were involved in 12/13 cases. 10/13 had leukopenia and 4/13 were thromobocytopenic.  Just another organism to add to your differential diagnosis!

As of the week of August 8-14 the Florida Department of Health has identified 28 cases of locally acquired dengue fever in Key West and one case in Broward County.

A serosurvey of 240 randomly selected Key West residents during September 23-27, 2009 revealed that 5.4% of residents had serologic evidence of recent infection with Dengue Fever Virus (DFV).

Dengue is the most common vector borne viral illness in the world, causing an estimate of 50-100 million infections and 25,000 deaths each year worldwide. Prior to the first Key West case report in August 2009, not a single case of locally acquired dengue had been reported in Florida since 1934. Only sporadic cases of dengue have been reported in the USA since 1980, and all were along the Texas-Mexico boarder.

Most cases of dengue fever (especially in children) are either completely asymptomatic, or cause a non-specific febrile illness. DFV, however can also cause more classic dengue infection with high fever, body aches, eye pain, rash, hemoconcentration, thrombocytopenia and leukopenia. Rarely, DFV can cause dengue hemorrhagic fever, with shock, and profuse bleeding.

Laboratory confirmation of DFV infection is by dengue-specific PCR from blood (collected within first 5 days of illness) or, seroconversion determined by a paired acute and convalescent phase titers (collected between days 6 and 30 after symptom onset). Probable cases can be determined by a single positive IgM antibody in a serum specimen.

There is no vaccination or anti-viral medication for the treatment or prevention of DFV infection. Therefore, mosquito avoidance measures are of utmost importance. Eliminating standing water outdoors to decrease mosquito breeding populations, the use of insect repellant, and avoidance (if possible) of being outdoors during early dawn or dusk hours are recommended.

MMWR/May 21, 2010/Vol. 59/ No. 19

State of Florida Department of Health

Health care providers seeing patients with dengue-like illness who have recently traveled to Puerto Rico, Key West, Florida or international dengue-affected areas (View maps online of world distribution of dengue) should report cases to the local or state health department and send specimens for laboratory testing. DF and DHF are now nationally notifiable conditions in the United States. Please remember that apart from individuals traveling for tourism, individuals responding to international disasters (e.g., Haiti earthquake), participating in medical or religious missionary work, and individuals visiting friends and relatives are often returning from dengue-affected areas and should be evaluated for dengue infection if they present with dengue-like illness during or after their travel.

Reporting to local public health officials and consideration of hospitalization to initiate supportive care should not be delayed pending test results. Reporting suspected dengue cases will trigger a public health investigation and the implementation of prevention measures.

Specimens from patients with acute febrile illness, who returned from dengue-affected areas within the past 14 days, should be submitted to their local or state health department, if the health department laboratory offers dengue testing.  State health departments with the capacity to test for dengue include: AZ, CA, CT, FL, NY, PR, and TX.

If the local or state health department does not perform dengue testing, submit specimens directly to CDC laboratories in San Juan, Puerto Rico (link below). CDC offers free diagnostic testing for health care providers and confirmatory dengue testing for health department and private laboratories. A completed CDC Dengue Case Investigation Form must accompany the specimens for the appropriate testing to be performed.

The emergence of methicillin-resistant Staphylococcus aureus (MRSA) in bone infections has complicated the management of osteomyelitis. Currently, vancomycin or clindamycin are empirically used. At All Children's Hospital, the current clindamycin inducible-resistance is 21% and constitutive resistance is 10%.  Various case reports have been published using TMP-SMX to treat osteoarticular infections. The excellent bioavailability and broad-spectrum coverage makes TMP-SMX an option for osteomyelitis treatment.  We reviewed a hospital database between October 1998 and September 2008, 37 children received TMP-SMX for confirmed or suspected Staphylococcus aureus (SA) osteomyelitis. Medical records were reviewed for safety, clinical outcome, and outpatient follow-up.  The ages ranged from 6 weeks to 17 years.  Thirteen patients were identified that had adequate follow-up following hospital discharge.  Five of the 13 had cultures that grew SA (4 of 5 were MRSA).  Eight of the 13 had no positive cultures but infection was presumed to be caused by SA. TMP-SMX had to be changed due to adverse drug reactions (ADR) (rash or neutropenia) in 3 patients. All 13 patients were successfully treated. TMP-SMX may be an option in the treatment of acute osteomyelitis. All the patients were cured at outpatient follow-up. Ten of 13 completed a course of TMP-SMX, while 3 were changed to an alternative agent due to an ADR.

Abstract: Trimethoprim-Sulfamethoxazole for MRSA Osteomyelitis

Infectious Disease Society of America

Here are the highlights:

1. All children should receive age-appropriate immunization for pneumococcus, Hib and influenza. This includes giving Prevnar 13 up to 6 years of age for children who previously have received a full schedule with Prevnar (7 serotype version). A dose of Prevnar 13 may also be given to the implant receipients between 6 & 18 years of age.
2. The unconjugated 23-serotype pneumococcal vaccine (Pneumovax) should be given at or after 2 years of age.
3. Acute otitis media diagnosed in the first 2 months after implantation surgery should be treated with a parenteral antibiotic.
4. Acute otitis media always should be treated in children with cochlear implants.
5. These patients do not have an increased risk of meningococcal infection.
6. Empiric therapy of meningitis that occurs within the first 2 months after surgery should cover pneumococcus and gram-negatives (e.g. vancomycin and meropenem).

Rubin LG, et al. Pediatrics 2010;126:381-91.

www.pediatrics.org/cgi/doi/10.1542/peds.2010-1427

1. Healthy children with head lice should not be excluded from school and "no-nit" policies for school return should be abandoned.
2. Infestations should be treated with 1% permethrins or pyrethrins unless resistance has been documented in the community.
3. Options for treatment of lice resistant to permethrins or pyrethrins include benzyl alcohol 5% in children over 6 months, malathion 0.5% in children over 2 years, an occlusive method (petroleum jelly or Cetaphil) or "wet-combing" in 2 weekly cycles.

Frankowski BL, et al. Pediatrics 2010;126:392-403

www.pediatrics.org/cgi/doi/10.1542/peds.2010-1308