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A Message from David Berman, D.O.
Pediatric Infectious Disease Program
All Children's Specialty Physician
All physicians are encouraged to complete the brief survey regardless of your opinion regarding childhood vaccination. |
Thank you for your participation.
|Immunization Action Coalition|
The Immunization Action Coalition (IAC) publishes Needle Tips, a newsletter for all healthcare professionals who give vaccines. Also available is Vaccinate Adults, a version of Needle Tips modified for those who work only with adult patients. Both are now available for online reading and/or printing.
These publications contain ready-to-print educational materials for healthcare professionals and their patients, updated immunization schedules, vaccine news highlights, and IAC's popular "Ask the Experts" question-and-answer column with answers by CDC experts William Atkinson, MD, MPH, and Andrew Kroger, MD, MPH.
Needle Tips and Vaccinate Adults are available exclusively online. Current and past issues of Needle Tips are available at www.immunize.org/nt and Vaccinate Adults at www.immunize.org/va.
To receive immediate notification when new issues are published, subscribe at www.immunize.org/subscribe. On this page, you can also subscribe to IAC's free weekly email news service, IAC Express, which keeps you up to date on immunization news between issues of IAC's periodicals.
|Short vs Long Term Therapy For Acute Osteomyelitis|
A recent prospective, randomized and controlled study from Finland compared a 20 vs. 30-day course of (primarily) oral antimicrobial therapy for acute osteomyelitis in children ages 3 months - 15 years. Children were enrolled during the years 1983-2005. Most all cases (89%) were caused by Staphylococcus aureus, of which none of the isolates were methicillin-resistant Staphylococcus aureus (MRSA). Remaining cases were caused by various other organisms. Most children (if susceptibilities allowed) were randomized to treatment with either clindamycin or a first generation cephalosporin given primarily by oral route at high dose, divided four times daily. Antibiotic therapy was continued until CRP was <2 mg/dL no matter how high the ESR. Surgery for bone debridement and drainage of abscesses was kept to a minimum, and in most cases was only done for diagnostic purposes. The primary endpoint was full recovery without the need for additional antibiotics during the 12-month follow up period.
The authors found that the patients treated for 20 days vs. 30 days had good clinical response, rapid fall in CRP and had no increased risk for recurrence and sequelae. Shorter courses of antibiotics obviated the need for frequent monitoring of laboratory values and in most cases was well tolerated.
Whether these short courses of antibiotics can be initiated in the USA, however is still questionable since a high percentage of acute pediatric osteomyelitis is caused by community acquired methicillin-resistant Staphylococcus aureus (CA-MRSA). Certain CA-MRSA clones contain the Panton-Valentine leukocidin (pvl) gene which increases inflammation, abscess formation and ultimately virulence of the pathogen. Disease is often more severe, including more days of bacteremia, multiple site involvement and persistence of fever. In the Finnish study, for example, only two of 183 cases had even minor sequelae after their treatment. In contrast, major sequelae are common (up to one-third) among children with pvl-positive strains of CA-MRSA.
For selected patients without CA-MRSA disease, however, this study does provide excellent evidence that short courses of therapy may be very effective.
Peltola, H et al. PIDJ. Vol 29. No 12. Dec 2010. Pages 1123-28
Comment on by: Kaplan, S. PIDJ. Vol 29 No 12 Dec 2010 pages 1128-30.
|Under the Radar, but Completely Amazing!|
|The second intentional vaccine-associated eradication of a viral disease in the history of the world was just announced this fall. (The first, of course, was smallpox in 1980). Rinderpest, a measles-like virus that is 80% fatal in cattle has been eradicated from the earth, following a global vaccination effort that started in 1994. Walter Plowright, a British veterinary pathologist, developed the live-attenuated vaccine in the 1950's. The last case of this disease, which for 5000 years has caused famine throughout the world, was seen in Kenya in 2001. The official ceremony to commemorate this achievement will be in May 2011. |
We find it sad that an achievement of this magnitude did not garner much attention in the popular media.
McNeil, Donald, NYTimes. October 15, 2010
Nelson, JD and McCracken, GH. PIDJ. Yellowpages. December 2010.
|Vapor Rub and the Common Cold|
Many of us remember our parents or grandparents smearing that slimy, smelly vapor rub (a compound of camphor, menthol and eucalyptus oil) on our necks when we went to bed with a cold. A new study in Pediatrics suggests that that old-fashioned therapy may actually help kids (and their caretakers) get a better night's sleep-even if it does nothing to cure the cold! Paul, et al (Pediatrics, 2010) randomized 138 children ages 2-11 without any underlying medical problems to receive no treatment, petrolatum rubs or vapor rubs to their neck and upper torso when they had the common cold. Physicians were blinded as to which therapy they received. Parents were asked to fill our surveys relating to the frequency and severity of their child's symptoms and were asked to rate their ability to sleep. Though the investigators attempted to blind the parents as to whether their child received vapor rubs vs. petrolatum, this ultimately proved difficult due to the characteristic smell and feel of the vapor rub.
The children who received therapy with vapor rub scored significantly better than those children in the "no treatment" or "petrolatum-treated" groups in terms of reduction in frequency of cough, and reduction in severity of cough and congestion, and scored better in ability to sleep. Parents' assessment of their own ability to sleep was also improved in the vapor rub treated group. The petrolatum group faired better than the no treatment groups in cough frequency and did fare marginally better in the overall combined symptom score--a result possibly offset by the finding that the parents of the children in the petrolatum group reported administering acetaminophen to their children more often than in the no treatment group (35% vs 9%). Finally, the incidence of adverse events was significantly higher in the vapor rub group than any other group. Mild burning sensation to the skin was the most commonly reported adverse event.
With the new guidelines recommending against the use of oral mediations in children for symptomatic cough and cold relief, very little is left for treatment of colds in kids. Topical application of vapor rub for children > 2 yrs may help them to at least get a good night sleep-while their t-lymphocytes ultimately do the work in getting rid of the virus!
Paul, IM. Et al. Pediatrics 2010; 126:1092-99.
|Group Child Care and Rate of Infections in the Short and Long Term|
|Preschool-aged children who attend large day care centers experience more frequent upper respiratory and ear infections than do their counterparts who are cared for at home. However, the observation has often been sited that these children are less often sick in their early school years. The Quebec Longitudinal Study of Child Development sought to put this hypothesis to the test. In their study of 2023 Canadian newborns, Cote, et al conducted yearly home interviews with the parent of these children from ages 5 months (1998) to 8 years (2006). Parents were asked questions about daycare attendance, type of daycare setting, and frequency of upper respiratory infections, ear infections and gastroenteritis, as well as other pertinent demographic data and baseline medical data. |
Results demonstrated that children who began attending large day care centers early on in childhood (at age <2.5 years) did have a greater frequency of colds and ear infections (there was no difference in gastroenteritis rates) but this same group of children also experienced significantly fewer colds and ear infections during early elementary school years. Children who started large day care centers later in childhood (>2.5 years) had no greater frequency of disease than children who stayed home and derived no protection from these illnesses in their elementary school years.
Cote, SM et al. Arch Pediatr Adolesc Med; 164(12) Dec 2010.
|Yet Another Reason to Get Your Flu Shot|
C Moore, et al recently reported the first evidence of person-to-person transmission of oseltamivir-resistant 2009 H1N1 influenza in 8 patients in Wales, UK. Transmission occurred in an outbreak in a hematology-oncology unit. Of notable concern was the fact that in 4 of 8 of these cases, the resistant virus was detected in pre-treatment specimen, suggesting that it was the resistant virus itself that was transmitted to the patients (rather than resistance which developed after treatment exposure). The average time for viral excretion in these largely immunocompromised patients was 17 days with a range of 6-30 days. Mild symptoms and asymptomatic illness were common with this strain, which, though good news for the sick patients, unfortunately exacerbates its spread by making it hard to identify sick patients.
Moore, C, et al. JID 2011:203, p 18-24
|Human Paragonimiasis associated with raw/undercooked crawfish|
Adding to the list of reasons why crawfish lovers should make sure to thoroughly cook their food: Paragonimiasis. What's that you ask? It is a parasitic disease caused from Paragoniumus trematodes (lung flukes). The disease most frequently affects the lungs but can also cause infections of other organs including the brain and skin. Though most common in tropical areas of Africa, Asia and the Americas, a recent increase in cases was reported in Missouri. Between 2006 and 2010, six cases were reported to the Missouri health department, all acquired locally. Before that time only six non-imported cases of this disease had been documented from 1965-2007. All nine patients presented with fever, cough, pleural effusion and eosinophilia. All had ingested raw or undercooked crawfish from various Missouri rivers from 2-16 weeks prior, often after alcohol consumption or in response to a dare (8 were males). Diagnosis was made in most cases by ELISA or immunoblot testing, and in 2 cases by direct visualization of the parasite or eggs on sputum cytology. All patients were treated with praziquantel and rapidly improved.
This report highlights the importance of anticipatory guidance for our patients regarding food safety. Also, health care providers should consider paragonimiasis in the differential diagnosis of patients with unexplained fever, cough, eosinophilia and pleural findings, especially if there is a history of raw crawfish consumption.
MMWR. Dec 10, 2010 59(48); 1573-76.
|Sustained protection against rotavirus from Pentavalent rotavirus vaccine|
JA Boom, et al. conducted a case-controlled study during the 2008 and 2009 rotavirus seasons in Houston, TX, to calculate vaccine effectiveness against severe rotavirus disease during the first two years of the vaccination program. Case patients consisted of patients with acute gastroenteritis (AGE) who tested positive for rotavirus. Control patients were age-matched patients who had acute respiratory infection (ARI) and children with rotavirus negative AGE. A total of 117 case patients (rotavirus positive), 444 ARI control patients and 248 rotavirus-negative AGE control-patients were identified. Among rotavirus positive patients 79% had had no doses of the rotavirus vaccine compared with 38% of ARI controls and 37% of rotavirus negative AGE controls. Additionally, only 12% of rotavirus positive cases had had all three doses of rotavirus vaccine compared with 28% of ARI and 35% or rotavirus-negative AGE controls. This translates to the rotavirus vaccine being 80% effective in preventing severe rotavirus compared with ARI controls and 78% effective when compared with rotavirus negative AGE controls. Additionally, when broken down by age, the rotavirus vaccine was 92% (compared to ARI controls) and 93% (compared to rotavirus-negative AGE controls< 12 months old). Among children >/= 12 months old the numbers were 84% (compared to ARI controls) and 78% (compared to rotavirus negative AGE controls).
Boom, JA. PIDJ. 29(12) Dec 2010.
|Future treatment for C. difficile Infection|
A major problem over the last decade has been the increasing incidence and severity of C. difficile associated diarrhea. This has been largely due to the emergence of the more virulent epidemic strain (North American Pulsed Field type 1 strains). More relapse has been seen upon completion of therapy, especially with the use of metronidazole. Vancomycin is used orally for patients that have frequent relapse. One of the problems with vancomycin is that it also can induce vancomycin resistance in normal flora. A recent clinical trial compared a new drug, fidaxomicin (OPT-80, Optimer Pharmaceuticals) with vancomycin in adult patients.
The clinical trial was designed as a non-inferiority trial. It was prospective, multicenter, double-blinded and randomized to either 10-days of fidaxomicin or vancomycin involving 52 sites in the US and 15 sites in Canada. Patients with life-threatening disease related to C. difficile, inflammatory bowel disease or more than one recurrence of infection within 3 months of study were excluded. Overall, 629 patients were enrolled, of whom 548 could be evaluated.
Clinical cure rates with fidaxomicin were non-inferior compared to vancomycin. Significantly fewer patients had recurrences in the fidaxomicin group if they were infected with the non-epidemic strain. Both drugs had similar adverse-event profile. However, rates of recurrence were similar between both groups with the epidemic strain. The median time to resolution of diarrhea was shorter in the fidaxomicin group. No changes in drug susceptibility to C. difficile occurred during the study in either group.
Potential advantages of fidaxomicin include less broad-spectrum antimicrobial activity, high fecal concentrations, low systemic absorption and twice daily dosing. Fidaxomicin is not yet available in the US, but it is currently being reviewed by the FDA.
New England Journal Medicine 2011;364:422-31.
|Curry for the Prevention of C. difficile Infection|
Investigators from Cedars Sinai Medical Center in Los Angeles, presented research regarding the ability of a commonly used spice, turmeric, to inhibit the growth of C. difficile in-vitro. Curcumin is found in turmeric. Turmeric is used in many Indian dishes.
Different concentrations of curcumin were used in-vitro against twenty-one strains of C. difficile. Growth of C. difficile was inhibited by concentrations of 128 micrograms/ml. The researchers have hypothesized that using up to four grams a day of curcumin may inhibit the growth of C. difficile in the stool. The spice turmeric could help prevent future infection of C. difficile in humans. The same group of researchers is now developing a clinical trial with curcumin to test their hypothesis.
Clinical Infectious Disease Journal 2010
American College of Gastroenterology's (ACG) 75th Annual Scientific meeting in San Antonio, Texas
|Normal Cerebrospinal Fluid Values in Febrile Infants without Meningitis|
A recent restrospective study evaluated three cohorts (different time periods over 13 year span) of infants at the University of Pittsburgh. This is the first study comparing CSF parameters weekly in the first 8 weeks of life in full-term infants (different categories starting day 0-7, 8-14, and so on through day 60). They compared CSF WBC in the 3 cohorts and protein /glucose in 2 cohorts. After exclusion criteria, 1091 infants were included in the final study group.
CSF WBC and protein values decreased as the age of the infant increased weekly but there was no clear relationship between glucose values and age. Mean CSF WBC values for 0-1-week-old infants were 8.6 WBC (26 WBC 90th percentile) and for infants 1-8 weeks old 3.6 WBC (6-9 WBC 90th percentile). Mean CSF protein was 106 (153 protein 90th percentile) in the 1st week of life and was 63.8 for weeks 2-8 (84-106 protein 90th percentile).
Pediatr Infect Dis J April 2011;30 (4)
|Viral Gastroenteritis in Pediatrics|
Viruses are the leading cause of gastroenteritis in pediatrics. Although mortality is lower in the United States as compared to developing countries, these pathogens are still responsible for significant morbidity in the United States. The enteric viruses cause infection in the intestine. Most cause GI symptoms. However, the enteroviruses, although their primary site of infection is intestinal, typically cause extraintestinal disease. The other viruses include the caliciviruses (Norwalk-like and Sapporo-like), astroviruses and enteric adenoviruses.
The caliciviruses are the leading cause of viral gastroenteritis outbreaks involving all age groups in various settings. Norwalk-like viruses are commonly implicated in outbreaks of gastroenteritis on cruise ships and other group settings. The virus can be spread by contaminated water or food, the environment and direct person-to-person contact. Incubation period is short (24-48 hours) and symptoms typically last 24-60 hours. The goal is to replace fluid losses. The Sapoviruses usually infect younger children and are not as severe as Norwalk-like viral illness. Incubation period is also short and the disease does not last longer than 3 to 4 days.
Astroviruses are detected in up to 10% of sporadic cases of viral gastroenteritis. Children may shed these viruses for several weeks following an acute illness. Symptomatic disease usually resolves within 6 days.
Enteric adenoviruses occur throughout the year and usually infect younger children. Children can also have asymptomatic shedding beyond the "symptomatic" period. Symptoms are similar to rotavirus. High fever and upper respiratory symptoms typically do not occur with the enteric adenovirus.
How do we prevent transmission?
- Proper hand hygiene and food preparation
- Sanitary water supply
- Exclusion from public pools during periods of infection
|Suspected Herpes Zoster in Vaccinated Children|
A prospective study was undertaken to determine the proportion of suspected herpes zoster (HZ) that could be confirmed by varicella PCR as well as determining the proportion of HZ caused by vaccine-type virus. In addition, serologic data was collected (varicella IgG and IgM). Investigators in the US prospectively identified HZ cases in varicella-vaccinated children (1-18 years of age). If a vaccinated child developed HZ, samples were obtained from blood (serology) and scrapings of scab lesions or lesions without scab for PCR.
Fourteen previously vaccinated children were identified with HZ. The median age was 65 months (range, 25-151 months). Of the 14, four children had a history of wild-type varicella infection (3/4 had varicella infection prior to one year of age and prior to vaccination while the fourth child had natural varicella infection 2 years after vaccination).
Thirteen skin specimens were submitted from 14 children and 6/14 were PCR-positive. Of the samples that were PCR positive, only 2 had vaccine-type virus. Acute sera available among the 13 patients had detectable varicella IgM antibody only in one patient. And as expected, all 13 had detectable varicella IgG antibody.
None of the children had fever and the majority of children had thoracic rash distribution. During the 66-month follow-up, there was only one complication. A child developed contact dermatitis almost 2 weeks after HZ rash.
Despite 2 children developing HZ related to vaccine-type virus, studies among children suggest a lower risk of HZ in vaccinated children compared to those children with natural varicella infection. There is little value in obtaining serology under these circumstances.
PIDJ 2011;30 (8) Brief Reports
|New ACIP Recommendations for Immunization with Quadrivalent Meningococcal Conjugate Vaccine (MCV) for Persons with Specific Immunodeficiencies and Routine Booster Dose of MCV for Adolescents |
Recommendation for Persons Aged 2 Through 54 Years with Reduced Immune Response
Persons 2 through 54 years old who have either 1) a persistent complement component deficiency (e.g., C5--C9, properidin, factor H, or factor D) or asplenia should receive a 2-dose primary series administered 2 months apart and then receive a booster dose every 5 years. These recommendations are based on prospective serologic data suggesting that the immune response to a single dose of meningococcal conjugate vaccine may fall below protective levels five years after a single dose.
Adolescents aged 11 through 18 years with HIV infection
Adolescents aged 11 through 18 years with HIV infection should be routinely vaccinated with a 2-dose primary series. Other persons with HIV who are vaccinated should receive a 2-dose series administered 2 months apart.
Recommendation for Routine Vaccination of Persons Aged 11 Through 18 Years
Adolescents aged 11 through 18 years should receive routine vaccination at age 11 or 12 years, with a booster dose at age 16 years. For adolescents who receive the first dose at age 13 through 15 years, a one-time booster dose should be administered, preferably at age 16 through 18 years, before the peak in increased risk. Persons who receive their first dose of meningococcal conjugate vaccine at or after age 16 years do not need a booster dose.
Note that routine vaccination of healthy persons who are not at increased risk for exposure to N. meningitidis is not recommended after age 21 years.
CDC Guidance for Transition to an Adolescent Booster Dose
Some schools, colleges, and universities have policies requiring vaccination against meningococcal disease as a condition of enrollment. For ease of program implementation, persons aged 21 years or younger should have documentation of receipt of a dose of meningococcal conjugate vaccine not more than 5 years before enrollment. If the primary dose was administered before the 16th birthday, a booster dose should be administered before enrollment in college. The booster dose can be administered anytime after the 16th birthday to ensure that the booster is provided. The minimum interval between doses of meningococcal conjugate vaccine is 8 weeks.
No data are available on the interchangeability of vaccine products. Whenever feasible, the same brand of vaccine should be used for all doses of the vaccination series. If vaccination providers do not know or have available the type of vaccine product previously administered, any product should be used to continue or complete the series.
A meningococcal conjugate vaccine information statement is available: http://www.cdc.gov/vaccines/pubs/vis/default.htm, and details regarding the routine meningococcal conjugate vaccination schedule are available at http://www.cdc.gov/vaccines/recs/schedules/default.htm#child. Adverse events after receipt of any vaccine should be reported to the Vaccine Adverse Event Reporting System at http://vaers.hhs.gov .
Morbidity and Mortality Weekly Report (MMWR). January 28, 2011 / 60(03);72-76.
|Morbidity and Mortality due to Foodborne Pathogens in the US|
The Centers for Disease Control and Prevention (CDC) has provided comprehensive estimates of foodborne illnesses, hospitalizations, and deaths in the US caused by known pathogens.
Norovirus caused the most illnesses; nontyphoidal Salmonella spp., norovirus, Campylobacter spp., and T. gondii caused the most hospitalizations; and nontyphoidal Salmonella spp., T. gondii, L. monocytogenes, and norovirus caused the most deaths.
The CDC estimates that each year in the US, 31 pathogens caused 9.4 million foodborne illness with 5.5 million (59%) foodborne illnesses caused by viruses, 3.6 million (39%) by bacteria, and 0.2 million (2%) by parasites. The pathogens that caused the most illnesses were norovirus (5.5 million, 58%), nontyphoidal Salmonella spp. (1.0 million, 11%), C. perfringens (1.0 million, 10%), and Campylobacter spp. (0.8 million, 9%).
The CDC estimates that the 31 known agents of foodborne disease that resulted from contaminated food eaten in the US cause 55,961 hospitalizations. Of these, 64% were caused by bacteria, 27% by viruses, and 9% by parasites. The leading causes of hospitalization were nontyphoidal Salmonella spp. (35%), norovirus (26%), Campylobacter spp. (15%), and T. gondii (8%).
The CDC estimates that the 31 known agents of foodborne disease resulting from contaminated food eaten in the US caused 1,351 deaths. Of these, 64% were caused by bacteria, 25% by parasites, and 12% by viruses. The leading causes of death were nontyphoidal Salmonella spp. (28%), T. gondii (24%), L. monocytogenes (19%), and norovirus (11%).
Scallan, E., et. Al. Foodborne Illness Acquired in the United States-Major Pathogens, Emerging Infectious Diseases, Volume 17, Number 1-January 2011, 7
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