*"It doesn't matter if the cat is black or white as long as it catches
mice."*

Deng Hsaio P'ing

This a page for sharing "what works" as seen in the published literature
as well as what is done at sites that care for American Indian/Alaskan
Native children. If you have any suggestions, comments or questions
please contact Steve Holve, MD, Chief Clinical Consultant in Pediatrics
at steve.holve@tchealth.org

IHS Child Health Notes

April 2008

# Quote of the month

*"* What is research but a blind date with knowledge."

Will Henry

**Article of Interest**

Estimating the effectiveness of screening for scoliosis: a case-control
study.

Pediatrics. 2008 Jan;121(1):9-14.

Does screening for scoliosis lead to earlier detection and decrease the
need for surgical treatment? The answer to the first question is "yes".
Disappointingly, the answer to the second question appears to be "no".

This was a case control study done in the Netherlands. Patients who
underwent screening were diagnosed with scoliosis at an earlier age
(10.8 years versus 13.4 years) but earlier detection did not decrease
the eventual need for surgical treatment. This also calls into question
whether earlier detection and bracing is effective. The authors suggest
that a randomized controlled trial of screening and bracing is needed to
definitively resolve this question.

**Editorial Comment**

Screening programs for scoliosis have been around for over 30 years. In
the United States 26 states actually mandate school screening for
scoliosis. The belief is that with early detection, treatment of
scoliosis may be instituted sooner, thereby reducing the number of
patients who will require surgery or have crippling deformities.

To screen in such a manner that no one with scoliosis is missed, many
individuals are identified falsely as having scoliosis and are referred
for confirmation by the pediatrician or orthopedist. Because so many
patients are identified falsely, the true cost of screening is
unacceptably high. There may also be significant emotional baggage in
being identified incorrectly with scoliosis or with scoliosis that is
clinically trivial. Given that the benefits are unproven, and that the
economic and emotional costs are high, school screening programs for
scoliosis have been discontinued in Great Britain and Canada. The
American Academy has no policy specifically addressing school screening
for scoliosis but does endorse scoliosis evaluation as part of well
child care for teens.

Until a definitive randomized controlled trial demonstrates the benefit
of school screening for scoliosis it is perhaps better to focus our
efforts on screening and treatments with proven benefits.

**Infectious Disease Updates**.

Rosalyn Singleton, MD, MPH

Here's recent news highlights from the world of vaccines:

1.  The Advisory Committee on Immunization Practices recommended in
    February to expand recommendations for yearly flu vaccine to all
    children 6 months to 18 years. An additional 30 million children
    will be recommended to receive flu vaccine.

> *Comment: This makes sense from a disease transmission standpoint. The
> Japanese showed an overall decrease in influenza illness among all
> ages when school-aged children were required to receive flu vaccine.
> While this is welcome news, I find this a little daunting because of
> all the shots we currently give. Could be a strong case for nasal
> FluMist®.*

2.  Merck's *ProQuad* Vaccine linked to more Seizures: A study presented
    to the ACIP last month has found that the Merck combination
    MMR-Varicella vaccine has been associated with higher rates of
    fever-related convulsions in children. The study found a two times
    higher rate of seizures in children who received the vaccine than in
    those who received separate MMR and Varicella. The excess number of
    seizures was estimated at 5 per 10,000. Although researchers could
    not isolate factors causing increased rates of fever-related
    convulsions, they did note that *ProQuad* contained five times more
    varicella antigen than Varivax®.

> *I can't comment on this issue since we haven't used ProQuad in Alaska
> (We don't have a way to keep it frozen in transit here in the cold
> north!)*

3.  Two recent Measles outbreaks in the US underscore the need to
    maintain high vaccination coverage, and the impact of "vaccine
    refusals":

    a.  A Japanese ballplayer traveled while sick with measles to the
        Little League World Series, causing measles to erupt in
        Pennsylvania, Michigan and Texas!

    b.  A child traveling from Switzerland to San Diego exposed numerous
        children at schools, parks, circuses and clinics resulting in 11
        confirmed cases of measles. Health officials say the outbreak
        should prompt parents to get their children vaccinated, as all
        of the confirmed cases involve children who did not receive the
        measles shot due to their young age or whose parents opted not
        to have them vaccinated.

> *Comment: I think it's important for folks who refuse vaccines out of
> fear to understand some of the risks. These are great lessons!*

**Recent literature on American Indian/Alaskan Native Health**

Michael L. Bartholomew, MD

Reingold A, Hadler, J, Farley MM, Harrison GL, Lynfield R, Lexau, Benett
N, Thomas A, Craig AS, Smith PJ, Beall B, Witney CG, Moore M, Pilishvili
T. Invasive Pneumococcal Disease in Children 5 Years After Conjugate
Vaccine Introduction\-\--Eight States, 1998-2005. *MMWR Morb Mortal Wkly
Rep*. 2008 Feb 15;57(06);144-148.

This study investigates invasive pneumococcal disease (IPD) trends in
children 5 years and younger pre- and post-introduction of 7-valent
pneumococcal conjugate vaccine (PCV7) in 8 states from 1998 to 2005
through analysis of CDC's Active Bacterial Core (ABCs) surveillance data
(population and laboratory-based surveillance data). Their results
indicate that the incidence of IPD among children \<5 years in 1998-1999
(pre-PCV7 vaccine years) were 98.7 cases per 100,000 while in 2005 the
rate was 23.4 cases per 100,000 giving an overall rate reduction of 77%!
Rates of IPD declined across all age groups with the largest absolute
rate reduction {175.7 per 100,000 (82%)} in children aged 1 year
(largest baseline rate).

The painted picture may not be "so rosy." Non-PCV7 IPD appears to be on
the rise. Further evaluation of the data indicates a leveling off of IPD
rates from 2002 to 2005. This steady state is in large part due to
non-PCV7 IPD, particularly the 19A serotype. In 2005, the incidence of
19A serotype IPD was 9.3 cases per 100,000; an increase from 2.6 cases
per 100,000 in 1998-1999. In 2005, 40% of IPD were related to non-PCV7
serotypes.

Singleton et al^1^ illustrated a similar trend in IPD in Alaska Native
children. For Alaska Native children less then 2 years of age, the
overall all IPD rate reduction was 67% (from 403.2 cases per 100,000 in
the pre-PVC7 vaccine years of 1995 through 2000 to 134.3 cases per
100,000 in 2001-2003). The rate of IPD attributed to PVC7 covered
serotypes (PVC7 IPD) in 1995-2000 was 275.3 per 100,000. After
introduction of PCV7 there was a 92% reduction to 23.4 per 100,000 by
2001-2003 in PVC7 IPD. By 2004-2006, the rate reduced further to 10.6
PVC7 IPD cases per 100,000. These advances in rate reduction were off
set by increases in non-PVC7 IPD seen in the Alaska Native children
population. The rate of non-PVC7 IPD prior to introduction of PVC7 in
children less than 2 years was 95.1 per 100,000. Through 2006, this rate
increased by 140% to 228.6 cases of non-PVC7 IPD per 100,000. This rate
more than doubled between 2001-2003 and 2004-2006. A majority of these
non- PVC7 IPD cases were caused by serotype 19A.

Both studies support the development of expansion of the valency of
conjugate vaccines to protect against serotypes not included in the
current PCV7 vaccine, especially serotype 19A. Time will tell whether
expansion will be beneficial in further reducing IPD rates, elimination
of health disparities as it relates to IPD, and improvement in the
health status of AI/AN children. As Dr. Esposito would say, "I will try
to keep you posted."

Reference:

1.  Singleton RJ, Hennessy TW, Bulkow LR, Hammitt LL, Zulz T, Hurlburt
    DA, Butler JC, Rudolph K, Parkinsn A. Invasive Pneumococcal Disease
    Caused by Nonvaccine Serotypes Among Alaska Native Children With
    High Level of 7-Valent Pneumococcal Conjugate Vaccine Coverage.
    *JAMA*. 2007;297:1784-1792.

> http://www.ncbi.nlm.nih.gov/pubmed/17456820?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum