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

*Chinese Proverb*

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 sholve@tcimc.ihs.gov

IHS Child Health Notes

**October 2007**

# Quote of the month

*"Nothing significant will ever be accomplished if all possible
objections must be dealt with beforehand."*\
Winston Churchill

**Articles of Interest**

A randomized, controlled trial of a removable brace versus casting in
children with low-risk ankle fractures.\
Pediatrics. 2007 Jun;119(6):e1256-63

<http://pediatrics.aappublications.org/cgi/content/abstract/119/6/e1256>

Recent studies have shown that casting may not be necessary for some
common childhood fractures such as buckle fractures of the wrist. A
recent double blinded randomized controlled study in Canada looked at
treatment of low risk distal fibular fractures. They compared the
standard treatment of 4 weeks in a fiberglass walking cast with a
removable air stirrup ankle brace.

At 4 weeks post-injury the children with the ankle brace more likely to
have returned to regular activities. These children were more likely to
have been "very happy" with their treatment and had fewer unscheduled
return visits for complications. The cost of ankle bracing was also
lower.

**Editorial Comment**

This study is particularly helpful for IHS and tribal sites which are
often rural, remote and do no have ready access to orthopedic specialty
care. These low risk fibular fractures, like low risk wrist fractures,
can be treated with bracing in a primary care clinic. Patients get
better faster, with less complications of casting and costs are
minimized.

**Article of Interest**

**Superhero-related injuries in paediatrics: a case series**\
Patrick Davies, Julia Surridge, Laura Hole, and Lisa Munro-Davies\
Arch Dis Child 2007; 92: 242-243. doi:10.1136/adc.2006.109793

The authors describe five patients between the ages of 3 and 8 years of
age who sustained serious injuries while dressed up as superheroes (4
Spiderman, 1 Superman). They speculate that the wearing of full costumes
may have led children to believe their own powers had been given a super
boost. The authors, all British, describe, how "all were injured after
initiating flight without having planned for landing strategies".

The authors also point out that all of the injured were boys. Commercial
role models for girls are less likely to show risk taking behaviors:
there are no known instances of "My Little Pony" related injuries.

**Infectious Disease Updates**.

Rosalyn Singleton, MD, MPH

**Influenza Vaccination for 2007-8**

-   **Influenza disease Predictions for 2007-8**:

    -   Some experts are predicting that the 2007-8 Flu season could be
        the worst in years. Australia is facing its worst influenza
        season since 2003 and it's possible the U.S. may expect the
        similar pattern after two mild seasons.

-   **IHS Childhood Influenza Immunization Rates, 2006-7**

    -   In the IHS 3^rd^ Quarter Immunization Report, among 9 reporting
        IHS Areas, 55% (range 14% to 65%) of 6-23 month old children
        received at least 1 influenza vaccine during the 2006-7 season.

-   **Influenza vaccine Recommendations 2007-8
    (<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5606a1.htm>)**

    -   Routine vaccination of 6-59 month olds

    -   Importance of 2 doses for children 6mo-8 yrs being vaccinated
        the first time

    -   **NEW!** Children 6mo-8yrs who received only 1 dose in their
        first year of vaccination should receive 2 doses the 2^nd^ year
        they are vaccinated

    -   Vaccination of household contacts and caregivers of children
        birth-59 months old.

    -   Timing of Influenza vaccine: Early October through March

    -   National Influenza Vaccination week is November 26 -- December
        2^nd^.

-   **Inactivated Influenza (TIV) Vaccine Products:**

  ----------------- ------------------ --------------- -------------------- ----------------
  **Vaccine**       **Package**        **Dose**        **Age**              **Thimerosal**

  Fluzone (Sanofi)  Multidose          Age-dependent   [\>]{.underline}6    Yes
                                                       mos                  

                    Single dose        0.25 mL         6-35 mos             No
                    syringe                                                 

                    Single dose        0.5 mL          [\>]{.underline}36   No
                    syringe                            mos                  

                    Single dose vial   0.5 mL          [\>]{.underline}36   No
                                                       mos                  

  Fluvirin          Multidose vial     0.5 mL          [\>]{.underline}4    Yes
  (Novartis)                                           yrs                  

  Fluarix (GSK)     Single dose        0.5 mL          [\>]{.underline}18   Trace
                    syringe                            yrs                  

  Flulaval (GSK     Multidose vial     0.5 mL          [\>]{.underline}18   Yes
                                                       yrs                  
  ----------------- ------------------ --------------- -------------------- ----------------

-   **Live attenuated Influenza Vaccine (LAIV):**

    -   New refrigerated (NOT FROZEN) formulation this season

    -   Approved only for 5-49 year old healthy persons -- Medimmune is
        applying for expansion of the licensure down to 1-2 years of
        age. Should hear soon!

-   **Flu Vaccine Supply predictions:**

    -   So far there are no predictions of vaccine shortages or delays.

    -   National Foundation of Infectious Disease planning a press
        conference Sept 19^th^

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

Doug Esposito, MD

**[Article]{.underline}**

Barry, M. The tail end of guinea worm -- global eradication without a
drug or a vaccine. *New Engl J Med*. 2007;365(25): 2561-4.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17582064&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum>

**Editorial Comment**

So, how does an article on the global eradication of dracunculiasis, or
guinea worm, relate to American Indian/Alaska Native Child Health?
Please read on to find out!

As most of you are aware, dracunculiasis is likely to become only the
second human disease in history to be eradicated from the face of the
planet through human intervention; the first, of course, being small
pox. From an estimated 3.5 million cases in 1986 to a few over 25,000
cases in 2006, and from 20 countries with endemic disease down to just 9
in the same period (five of which reported fewer than 30 cases each),
guinea worm is taking its last gasp (hmm\...do those little guys
actually breath?). What is so remarkable about this achievement, though,
is that this progress has been made without drugs or vaccines, and for a
total estimated cost of around \$250 million. The progress made to date
has almost entirely been accomplished through a grass-roots public
health movement and generalized changes in behavior of populations. "Its
demise will be proof that people can be persuaded to change their
behavior through innovative health education."

I will refer the reader to the article itself to review the specific
details of the dracunculiasis eradication effort and not repeat them
here. The point that I would like to make is that it really is possible
to change behavior on a population level, as evidenced by this
incredible achievement.

So why then is greater progress on such issues as obesity, diabetes, and
motor vehicle related morbidity and mortality so elusive? I suppose we
just haven't yet managed to get it right! The medical and public health
communities have not been able to make sufficient inroads into the
consciousness of the population as a whole or to counter the significant
social, political, and corporate forces that stand in opposition to
positive change. As such, a sufficient societal response to these
problems in the form of broad behavioral change has not yet been
achieved.

One might argue that the afflictions of the developed world are somehow
just a little more complex than a simple endemic helminthic infestation
of the developing world; that the interplay between health behaviors and
societal, political, and corporate forces are somehow more intricate in
the U.S. (please see the article in "Additional Reading" below for a
fascinating example of just one aspect of that complexity in our own
society). Yes, obesity is a difficult issue with complex and powerful
modulating forces at work. But no matter how simple the process of
collecting clean water in the developing world might seem, it is an
incredibly complex process that is subject in my opinion to many of the
same forces that have led to overeating, poor physical activity, and low
passenger restraint use rates in our world.

As overwhelming as health problems like obesity, diabetes, and injury
are, I for one take heart in knowing that successes like the impending
guinea worm eradication are possible, without drugs, immunizations,
complex technologies, or mega-bucks! Population-level behaviors that
result in disease and illness CAN be changed. The impossible really is
possible! I guess the bottom line is that we will just have to keep
trying until we get it right. We will get there, hopefully sooner rather
than later.

**Additional Reading**

Jones MM, Bayer R. Paternalism and its discontents: motorcycle helmet
laws, libertarian values, and public health. *Am J Public Health*. 2007
Feb;97(2):208-17.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17194856&ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum>

**[Article]{.underline}**

[Brugge D, Delemos JL, Bui
C.](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17666688&ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum)
The Sequoyah Corporation fuels incident and the Church Rock spill:
unpublicized nuclear releases in American Indian communities. *Am J
Public Health*. 2007;97(9): 30-5.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17666688&ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum>

**Editorial Comment**

This is an interesting article about two significant accidental nuclear
releases into the environment that occurred in two American Indian
communities and the possible reasons why these events never really
received much interest or mention in the press or the scientific
literature. In fact, I had never really heard of either, despite the
fact that the largest of the two incidents (the Church Rock, NM incident
was more than three times larger in terms of estimated curies of
radiation release than the infamous Three Mile Island incident!)
occurred less than 45 miles from where I now reside! The authors contend
that the reason so little interest has been paid to these two incidents
might have something to do with their having occurred in rural,
low-income, American Indian communities. I would suggest reading this
interesting article and deciding for yourself.

# Announcements from the AAP Indian Health Special Interest Group 

Sunnah Kim, MS **Locums Tenens and Job Opportunities**

If you have a short or long term opportunity in an IHS, Tribal or Urban
facility that you'd like for us to publicize (i.e. AAP Web site or
complimentary ad on Ped Jobs, the official AAP on-line job board),
please forward the information to <indianhealth@aap.org> or complete the
on-line locum tenens form at <http://www.aap.org/nach/locumtenens.htm>

.