Annabelle de St. Maurice

Racial and Regional Differences in Rates of Invasive Pneumococcal Disease

BACKGROUND AND OBJECTIVES: Invasive pneumococcal disease (IPD) remains an important cause of illness in US children. We assessed the impact of introduction of the 13-valent pneumococcal conjugate vaccine (PCV13) on pediatric IPD rates, as well as changes in racial and regional differences in IPD, in Tennessee. METHODS: Data from active laboratory and population-based surveillance of IPD were used to compare IPD rates in the early-PCV7 (2001–2004), late-PCV7 (2005–2009), and post-PCV13 (2011–2012) eras. IPD rates were further stratified according to age, race, and region (east and middle-west TN). RESULTS: Among children aged <2 years, IPD rates declined by 70% from 67 to 19 per 100 000 person-years in the early-PCV7 era and post-PCV13 era, respectively. Similar decreasing trends in IPD rates were observed in older children aged 2 to 4 years and 5 to 17 years. In the late-PCV7 era, IPD rates in children aged <2 years were higher in black children compared with white children (70 vs 43 per 100 000 person-years); however, these racial differences in IPD rates were no longer significant after PCV13 introduction. Before PCV13, IPD rates in children aged <2 years were also higher in east Tennessee compared with middle-west Tennessee (91 vs 45 per 100 000 person-years), but these differences were no longer significant in the post-PCV13 era. CONCLUSIONS: PCV13 introduction led to substantial declines in childhood IPD rates and was associated with reduced regional and racial differences in IPD rates in Tennessee.

Persistent Sex Disparities in Invasive Pneumococcal Diseases in the Conjugate Vaccine Era

BACKGROUND Few studies have characterized the role of sex on the incidence of invasive pneumococcal disease (IPD). We examined sex differences in rates of IPD, and trends after the introduction of pneumococcal conjugate vaccines (PCVs). METHODS We used active population and laboratory-based IPD surveillance data from the Centers for Disease Control and Prevention Active Bacterial Core surveillance program (1998-2013) in Tennessee. Population-based rates of IPD by sex, race, age group, and PCV era were calculated. Rates were compared using incidence rate ratios. RESULTS Throughout the study years, rates of IPD were higher in male than in female subjects, particularly in children <2 years and adults 40-64 years of age, with male subjects having IPD rates 1.5-2 times higher than female subjects. The proportions of comorbid conditions were similar in male and female subjects . Sex rate differences persisted after stratification by race. Although the introductions of 7-valent PCV (PCV7) and 13-valent PCV (PCV13) were associated with declines in IPD rates in both sexes, rates of IPD after PCV13 were still significantly higher in male than in female subjects among children and adults 40-64 and >74 years of age. CONCLUSIONS Rates of IPD were generally higher in male than in female subjects. These sex differences were observed in different race groups and persisted after introduction of both PCVs.

Prolonged fever and splenic lesions caused by Malassezia restricta in an immunocompromised patient

Malassezia species are commonly found on human skin as commensals but can cause invasive infections in premature infants and immunocompromised hosts. Due to their fastidious growth, diagnosis of Malassezia infections can prove challenging. Molecular techniques can aid in diagnosis and treatment of invasive infections. We describe the case of a pediatric oncology patient with splenic lesions secondary to Malassezia restricta.

Immunization and treatment updates: 2016-2017 influenza season

Influenza‐associated infections cause significant morbidity and mortality worldwide, particularly among immunocompromised patients. Immunization is the primary mode of prevention of disease; however, efficacy in immunocompromised patients may be limited. Antiviral medications are important for treatment and prophylaxis of affected individuals. This article reviews treatment and prevention recommendations for the 2016‐2017 influenza season in the Northern Hemisphere and Southern Hemisphere.

The Pediatric Subspecialty Match: Past, Present, and Future.

T he Council of Pediatric Subspecialties (CoPS) was formed in 2006 to facilitate communication and collaboration among pediatric subspecialty organizations. One of its first undertakings was an assessment of the pediatric subspecialty application process. At the time, pediatric residents felt pressured into choosing a subspecialty early in training, with many starting the application process before the end of their first year of residency. In addition, most subspecialties did not have a standard application process, resulting in significant variation in the information requested by individual programs. In 2007, CoPS created a task force to evaluate these issues. After weighing the pros and cons of unifying the application process and surveying 1244 fellows, the task force made 2 recommendations: (1) all subspecialties were requested to use the Electronic Residency Application Service (ERAS); and (2) they were encouraged to consolidate their match dates to one of 2 options through the National Resident Matching Program (NRMP). These suggested match dates were in late spring (13 months prior to starting fellowship) and late fall (7 months prior to starting fellowship). Through continued dialogue and with the encouragement of CoPS, subspecialties gradually adopted these recommendations. In 2006, only 4 subspecialties used ERAS and 6 subspecialties participated in a match. By 2011, 14 subspecialties were using ERAS, with an even distribution between the 2 recommended match dates. Nonetheless, pediatric trainees continued to express concern over the early timing of the spring match, for which applications are typically submitted in early December of the second year of residency. For those in the Accelerated Research Pathway applying to subspecialties in the

Vaccine Hesitancy in Children—A Call for Action

Immunizations have made an enormous impact on the health of children by decreasing childhood morbidity and mortality from a variety of vaccine-preventable diseases worldwide. The eradication of polio from Nigeria and India is one of the most recent victories for one of the greatest technological advances in human history. Despite these international successes, the United States has experienced the re-emergence of measles, driven largely by increasing parental refusal of vaccines. Pediatricians should be trained to be very knowledgeable about vaccines and should continue to advocate for parents to immunize their children.

Post-Licensure Monitoring to Evaluate Vaccine Safety

See related article, p 576 neurologic symptoms, including encephalopathy and seizures. Prior to the introduction of pertussis vaccine in the US, there were about 157 cases of pertussis per 100 000 people each year, with 1.5 deaths per 1000 infants less than 1 year of age. Although disease rates were starting to decline prior to the introduction of vaccine, rates declined precipitously in the late 1940s when whole cell pertussis vaccine was recommended universally for young children. By 1973, rates of pertussis disease were only 0.5-1.5 per 100 000 population. However, because of significant local and systemic adverse reactions associated with the whole cell vaccine, acellular pertussis vaccines were introduced in 1996, with much fewer local and systemic adverse reactions. The study by Lateef et al in this issue of The Journal uses data from the National Vaccine Injury Compensation Program (VICP) to describe the characteristics of children whose parents or guardians submitted claims for seizure disorders and/or encephalopathy associated with vaccine administration. Many were associated with pertussis vaccines. However, there are several limitations to this study. First, VICP was not created to study the epidemiology of adverse vaccine events. It was established in 1986 as a mechanism to provide “no-fault” compensation for individuals injured by certain vaccines, termed “covered vaccines” within specific time periods after vaccine administration. The Vaccine Injury Table lists specific vaccine injuries and time frames that are reimbursable through the VICP and claimants are not required to prove causation. The VICP does not have comprehensive medical records and does not provide long-term follow-up on all claimants. In fact, Lateef et al reported that only 165 of 222 (74%) claims had sufficient information for a chart review and no data were provided on the characteristics of excluded cases. Of children who had sufficient data to be included, 80% had received pertussis vaccines, with a ratio of 3 times as many cases associated with whole cell vaccine as with acellular vaccine. Diagnostic evaluations on the awarded claims were limited. Although almost 80% of cases had some form of head imaging, only 18% of cases had a genetic workup, and there were no reports of the number of

Notes from the Field: Multiple Cases of Seoul Virus Infection in a Household with Infected Pet Rats — Tennessee, December 2016–April 2017

Multiple Cases of Seoul Virus Infection in a Household with Infected Pet Rats — Tennessee, December 2016–April 2017 Mary-Margaret A. Fill, MD1; Heather Mullins, MPH2; Andrew Stephen May, MD2; Heather Henderson, DVM1; Shelley M. Brown3; ChengFeng Chiang, PhD3; Nishi R. Patel, MS3; John D. Klena, PhD3; Annabelle de St. Maurice, MD3,4; Barbara Knust, DVM3; Stuart T. Nichol, PhD3; John R. Dunn, DVM, PhD1; William Schaffner, MD5; Timothy F. Jones, MD1

Addressing Vaccine Hesitancy in Clinical Practice

Vaccines have had a profound impact on public health; however, parents are increasingly refusing or delaying vaccines for their children. Population-based studies have demonstrated the safety and efficacy of vaccines. Pediatricians should be well informed about vaccine development, safety, and efficacy to inspire parental confidence in vaccines. Systemic challenges in discussing and providing immunizations exist. Discussions about immunizations may be lengthy and time spent discussing immunizations is not routinely reimbursed. Adolescents may be inadequately immunized because they do not routinely present for preventive health visits. Routine immunizations should be offered and discussed at sick visits, particularly for adolescents. Improving immunization rates requires a multifaceted approach. [Pediatr Ann. 2018;47(9):e366-e370.].