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

Deng Hsaio P'ing 1904-1997

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

September 2007

# Quote of the month

*"I am dying with the help of too many physicians"*

Alexander the Great, on his deathbed

**Articles of Interest**

Prevention of infective endocarditis: guidelines from the American Heart
Association: a guideline from the American Heart Association Rheumatic
Fever, Endocarditis and Kawasaki Disease Committee, Council on
Cardiovascular Disease in the Young, and the Council on Clinical
Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the
Quality of Care and Outcomes Research Interdisciplinary Working Group.\
J Am Dent Assoc. 2007 Jun;138(6):739-45, 747-60.

<http://dx.doi.org/10.1161/CIRCULATIONAHA.106.183095>

This is the first time that prophylaxis for infective endocarditis has
been written using evidenced based guidelines. The difference is
significant.

Overall the guidelines are much simpler and the need for antibiotic
prophylaxis is greatly reduced. Reviewing numerous studies the workgroup
determined that the overall risk of transient bacteremia is far greater
in everyday activities such as tooth brushing and dental flossing than
it is from dental procedures. They also acknowledge that recent studies
show that even in the best of circumstances that antibiotic prophylaxis
often fails to prevent infective endocarditis. They point out for
patients without significant cardiac risk factors undergoing routine
dental work that the overall risk of anaphylaxis and death is probably
greater from reactions to antibiotics than the risk of death from
infective endocarditis without the use of prophylactic antibiotics.

They recommend that only high risk patients need prophylaxis. They
listed patients with the following: previous infective endocarditis,
prosthetic cardiac valves, unrepaired congenital heart disease and
surgically repaired hearts with prosthetic materials or residual
defects. Prophylaxis is no longer required for mitral valve prolapse or
any gastrointestinal or genitourinary procedure. The complete text can
be read at:

**Editorial Comment**

Another case in which less is more. Previous guidelines were based on
expert opinion and fear. Numerous studies in the past decade have shown
that the risk of infective endocarditis is less than expected from
dental procedures. Share these guidelines with your colleagues in
dentistry.

.

**Infectious Disease Updates**.

Rosalyn Singleton, MD, MPH

 **RPMS Immunization Package: Version 8.2 coming this summer**

A new version of the RPMS Immunization Package will be out soon. Here
are the important new tools for providers included in this update:

1.  Human Papillomavirus (HPV) vaccine forecasting: Version 8.2 provides
    two forecasting options for HPV vaccine. Facilities can forecast HPV
    vaccine for 11-18 year old or 11-26 year old females.

2.  New Adolescent Report: provides immunization coverage rates for
    single vaccines (HepB, HepA, Td/Tdap, MMR, Varicella,
    MeningCV4,Influenza and HPV vaccines) and combinations (e.g., 3HepB,
    2MMR, 1Var, 1Td/ap) for adolescents 11-17 years old with 2 visits in
    the past 3 years.

3.  New Lot Number Inventory System: A new inventory system monitors
    vaccine stock by lot number. When the pharmacist enters a new lot
    number, they will input the expiration date, starting number of
    doses, and unused doses. The "doses unused" decreases each time an
    immunization of that lot number is entered into RPMS. Providers get
    an alert notice if they enter an expired vaccine lot or the supply
    is low.

4.  Meningococcal conjugate 4-valent (meningCV4, Menactra) forecasting
    is changed to forecast for all 11-15 year olds.

5.  New forecasting options: Versions 1, 3, 5, 7, 9 and 11 forecast the
    first vaccines series at 6 wks; the others beginning at 2 months.
    All versions forecast Rotavirus at 2 (6 wks), 4, and 6 months, Hep A
    starting at 15 months, and Influenza between Sept and March for
    infants 6-59 months. Option 11 does not forecast Hep A or Hep B in
    persons over 18 years, regardless of prior doses. All options
    forecast Tdap, MCV4, and HPV for adolescents per ACIP recs. For each
    of the options, the site can choose to use or not to use the 4 day
    grace period. The options are:

Option 6 Mths 12 Mths 15 Mths

\-\-\-\-\-- \-\-\-\-\--
\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-- \-\-\-\-\-\--

1\) \...\... IPV Hib, MMR, Pn, Var \..... DTaP

2\) \...\... \.... Hib, IPV, MMR, Pn, Var \...\... DTaP

3\) \...\... IPV DTaP, Hib, MMR, Pn, Var \.....

4\) \...\... \.... DTaP, Hib, IPV, MMR, Pn, Var.

5\) \...\... IPV Hib, MMR, Var \...\...\...\...\... DTaP,Pn

7\) Comvax IPV DTap, HepB, Hib, MMR, Pn, Var

9\) Comvax IPV HepB, Hib, Var, MMR \...\...\... DTaP,Pn

11\) \..... IPV Hib, MMR, Pn, Var \..... DTaP

> Figure 1-1: Screenshot of vaccine forecasting options

6.  Additional tools added in the recent Version 8.1\*1 patch:

    a.  Forecasting for Rotavirus (rota-pent, RotaTeq®) vaccine for all
        infants at 2 months (or 6 weeks), 4 months and 6 months.

    b.  Influenza vaccine routinely forecast for children 6-59 months

    c.  2^nd^ dose of Varicella forecast at 4-18 years

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

Doug Esposito, MD

**[Article]{.underline}**

In this issue of the IHS Child Health Notes, I will highlight two
articles that report data on substance abuse in Native American
communities. It is no secret that substance abuse poses a serious threat
to the health of children, youth, families, and communities all across
the nation. However, there is evidence to suggest that substance abuse
might pose an even greater threat to AI/AN populations. The two studies
being reviewed use different methods to investigate specific aspects of
substance abuse in distinct and diverse Native American communities.
Together, I believe these reports help shed considerable light on this
extremely important subject.

**[Article]{.underline}**

[Whitesell NR, Beals J, Mitchell CM, Novins DK, Spicer P, O\'Connell J,
Manson
SM.](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17538072&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum)
Marijuana initiation in 2 American Indian reservation communities:
comparison with a national sample. *Am J Public Health*. 2007
Jul;97(7):1311-8.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17538072&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum>

**Editorial Comment**

The authors assess risk of marijuana (MJ) initiation in two birth
cohorts (birth between 1944-1959 and between 1960-1976) in two distinct
tribal communities (Northern Plains and Southwest), and compare these
data with a national sample. Overall, findings show that MJ initiation
follows a similar pattern across study populations. MJ initiation risk
peaked at an identical point during adolescence in all groups suggesting
that prevention efforts should be focused before and during adolescence.
Between birth cohorts, MJ initiation peaked two years earlier in the
younger (at 16 years of age) cohort than in the older (at 18 years of
age) cohort, consistent with findings from other studies showing that MJ
initiation is occurring at a younger age over time. Females were found
to use MJ significantly less than males. This gender difference was
consistent across sample groups.

There were, however, some disparities in MJ initiation identified. Risk
for MJ initiation in the older birth cohort was highest among the
national sample, followed by the Plains group, with the Southwest
population having the lowest risk. In the younger birth cohort, risk in
the two American Indian populations was found to exceed that of the
national sample, with the Northern Plains group having the highest and
the Southwest group having an intermediate risk for MJ initiation.
Although the peak risk was similar in magnitude between the two birth
cohorts for the national sample, there was a significant shift upward in
risk of MJ initiation at all ages in the younger American Indian birth
cohort relative to the older birth cohort, i.e. American Indians born
later were significantly more likely to use MJ at each age. As the
authors point out, "although the trend toward earlier MJ initiation
crossed cultural lines, cohort differences in the degree of risk at each
age were apparent only in the American Indian communities." One
potential explanation for this finding is the possibility that certain
protective cultural factors present in the older AI cohort might have
eroded over time and have been less prevalent and therefore less
protective in the younger AI birth cohort.

One additional concept strengthened by this report is that of the
distinctness of individual Native American cultures. In many studies and
national surveys, the reporting of data gathered from Native Americans
is often lumped together under the "AI/AN" designation. This practice
represents a gross and potentially dangerous oversimplification,
resulting in an incomplete understanding of the Native American
experience. Native American cultures are distinct and highly diverse,
with varied histories, traditions, customs, and realities. Although
there are certainly some commonalities (i.e. poverty, geographic and
social isolation, cultural disintegration, inter-generational trauma,
limited access to care, etc.), the degree to which these and other
factors impact health and influence disease are not uniform. The
collective history of each culture has an important impact on health,
and the histories of Native Americans are not uniform. For these
populations, health status, health problems, and the determinants of
health are as diverse and variable as the individual cultures
themselves.

In the process of over generalizing, much important information is lost,
leading to an incomplete or erroneous understanding of health problems
and the eventual generation of ineffectual and poorly focused
interventions. More culture-specific information is desperately needed
pertaining to Native Americans and their health and wellness, and this
study represents a step in the right direction.

**[Article]{.underline}**

[Angstman S, Patten CA, Renner CC, Simon A, Thomas JL, Hurt RD,
Schroeder DR, Decker PA, Offord
KP.](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17402865&ordinalpos=7&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum)
Tobacco and other substance use among Alaska Native youth in western
Alaska. *Am J Health Behav*. 2007 May-Jun;31(3):249-60.
<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17402865&ordinalpos=7&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum>

**Editorial Comment**

This study was based on a medical records review of a sample of 680
children ages 6-18 who presented for a Well Child Assessment in the
Yukon-Kuskokwim Delta (Y-K Delta) region in Southwestern Alaska over a
12 month period in 2001-2002. The authors report very high rates of
early initiation of tobacco products, which was overwhelmingly in the
form of smokeless tobacco (ST). Twenty five percent of the 6-10 year
olds in this study report having ever used tobacco. Compare this to a
national survey of middle-school students in which only 8.4% reported
having smoked their first cigarette before age 11 and only 3.7% of
middle-school students reported having used ST before age 11. In the Y-K
Delta region/culture, use of a home made form of ST known as "Iqmik" is
very common, and although tobacco is not used ceremonially, Iqmik is a
culturally sanctioned activity with few adverse health effects perceived
by the population.

Although not surprising, the authors also report a steady increase in
tobacco use rates with age; rates that are substantially higher than
national rates at all ages, and that female use rates were consistently
higher than those seen for males. Factors associated with early tobacco
use were found to be receipt of offers to use tobacco and maternal
tobacco use. No other psychosocial or school achievement factors were
found in association as is typically reported in studies of other
populations.

Despite the limitations of this study (which are thoroughly described by
the authors), this article reports important information that will
certainly be of use in developing targeted tobacco prevention
interventions in the communities of the Y-K Delta.

**Additional Reading**

[Centers for Disease Control and Prevention
(CDC).](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17625495&ordinalpos=8&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum)
Prevalence of Cigarette Use Among 14 Racial/Ethnic Populations \-\--
United States, 1999---2001. *MMWR* 2004;53(03);49-52.

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5303a2.htm>

[Renner CC, Patten CA, Enoch C, Petraitis J, Offord KP, Angstman S,
Garrison A, Nevak C, Croghan IT, Hurt
RD.](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15020175&ordinalpos=5&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum)
Focus groups of Y-K Delta Alaska Natives: attitudes toward tobacco use
and tobacco dependence interventions. *Prev Med*. 2004 Apr;38(4):421-31.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15020175&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum>

# 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>

.