*"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

October 2005

# Quote of the month

*"The time to read is anytime: no apparatus, no appointment of time or
place is necessary."*

John Aikin (1747-1822)

**Articles of Interest**

Relationships between poverty and psychopathology: a natural
experiment.\
JAMA. 2003 Oct 15;290(15):2023-9.

<http://jama.ama-assn.org/cgi/content/full/290/15/2023?eaf>

**Summary**

Social causation (adversity and stress) versus social selection
(downward mobility due to mental illness) are competing theories about
the origins of mental illness. Halfway through an ongoing longitudinal
psychiatric study, a casino opened on an Indian reservation that gave
families an income supplement. A significant number of Indian families
moved out of poverty while non-Indian families in the study had no
change in economic status. There was a marked decrease in the number of
Indian children diagnosed with conduct and oppositional defiant disorder
but no change in anxiety or depression symptoms. The results suggest a
social causation explanation for conduct and oppositional defiant
disorder but not for anxiety or depression.

**Editorial Comment**

This article is two years old but raises lots of interesting questions.
Many of us have strong feelings about gambling in general and Indian
gaming in particular. This study takes the issue out of the moral arena
and asks about health effects of Indian gaming with some surprising
results. It touches on the larger question of the relationship between
health and economic status.

**Infectious Disease Updates**.

Rosalyn Singleton MD MPH

**Menactra®: Addressing a rare but deadly killer.**

*Neisseria meningitides* infects a small proportion of the general
population (\<1-5 per 100,000); however, despite its rarity,
meningococcal disease is important because of its high mortality rate --
10 to 25%. A quadrivalent polysaccharide vaccine (A, C, Y and W-135) has
been available; however, polysaccharide vaccines are poorly immunogenic
in children \< 2 years and do not induce immunologic memory. Serogroup
prevalence varies widely. In the US, serogroups C (28%), Y (34%), and B
(33%) were the most prevalent serogroups during 1995-1998. The highest
rate of meningococcal disease (5:100,000) occurs in infants; however, a
peak also occurs in 15-19 year olds.

In January the FDA licensed a new meningococcal quadrivalent (A, C, Y,
and W135) conjugate vaccine (Menactra®, Sanofi-Pasteur). Studies in
children showed superior immunogenicity and similar side effects
compared with the older polysaccharide vaccine (Menimmune®). In February
2005 the Advisory Committee on Immunization Practices (ACIP) voted to
recommend routine vaccination with Menactra® at pre-adolescent (11-12
year olds) with catch-up before high school entry (15 year olds), and
for college freshmen living in dorms, and other groups at highest risk
(eg. asplenia, terminal complement deficiency, military recruits,
travelers to or residents in countries with epidemic disease). Since
boarding schools pose similar risks of transmissions as dormitories,
individual Areas may want to extend vaccination recommendations to
include students between 11 and 18 years entering boarding schools. The
vaccine was added to the list of Vaccines For Children (VFC) eligible
vaccines.

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

Doug Esposito, MD

Confronting oral health disparities among American Indian/Alaska Native
children: The Pediatric Oral Health Therapist.

*Am J Public Health*. 2005;95(8):1225-29.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16006412&query_hl=2>

**Summary**

The authors outline the historical development and recent deployment of
Pediatric Oral Health Therapists in rural Alaska as a means of
addressing the disparities that exist with regard to dental health and
access to dental services in isolated Native communities. American
Indian/Alaska Native children suffer from the highest rates of tooth
decay and the poorest dental health in the Nation. For many, access to
dental service is severely limited. In Alaska, geographic isolation
serves as a significant barrier. Additionally, it has been extremely
difficult to attract dentists to rural and isolated areas, but not for
want of trying! The authors make a cogent moral and public health
argument in support of the Dental Health Aide and the Pediatric Oral
Health Therapist Program as it is currently being planned.

**Editorial Comment**

The interested reader will want to review the American Dental
Association's (ADA) negative view of the Pediatric Oral Health Therapist
Program as outlined in the May 2005 issue of the American Journal of
Public Health "Improving the Oral Health of Alaska Natives." Also of
interest is the Anchorage Daily News article "Dental Training Rouses
Protest from Dentists," which appeared on June 1, 2005. The integrity of
this rational and innovative approach to reduce dental health
disparities by increasing access to quality care for isolated
communities is jeopardized as a result of this ADA attack. Can valid
programs serving the greater good ever succeed when pitted against the
economic interests and controlling tendencies of relatively small
professional groups in a democratic capitalist society (yikes!)? Efforts
to develop oral health therapist programs have failed before in the
United States at the hand of such attacks, despite documented efficacy
and safety from other countries. Will this brave attempt also fail? Only
time will tell.

**Additional Reading**

Improving the oral health of Alaska Natives.\
*Am J Public Health*. 2005 May;95(5):769-73.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15855450&query_hl=1>

Dental training rouses protest from dentists. *Anchorage Daily News*.
June 1, 2005.

<http://www.adn.com/news/alaska/story/6556940p-6439704c.html>

Developing a pediatric oral health therapist to help address oral health
disparities among children. *J Dent Educ*. 2004 Jan;68(1):8-20.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14761168&query_hl=2>

**Article**

Community-onset methicillin-resistant *Staphylococcus aureus* associated
with antibiotic use and the cytotoxin Panton-Valentine leukocidin during
a ferunculosis outbreak in rural Alaska. *J Infect Dis*.
2004;189(9):1565-73.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15116291&query_hl=1>

**Highlights**

-   Despite its cumbersome (and perhaps frightening) title, it's a
    wonderful, relevant, and timely paper, and well worth reading.

-   The authors report their findings of risk factors associated with a
    particular community-onset MRSA (CO-MRSA) skin infection outbreak in
    a rural Alaska Native village.

-   Though causality could not be definitively established due to study
    design, use of antibiotics in the 12 preceding months was strongly
    associated with MRSA skin infection.

-   The Panton-Valentine leukocidin (PVL) genes were present in 97% of
    MRSA isolates, and in none of the methicillin-sensitive *Staph
    aureus* (MSSA) isolates. PVL is a virulence factor that has been
    associated with skin and soft tissue infection, and appears to play
    a significant role in the development of skin infections in Alaska
    as well.

-   "The emergence of MRSA strains that cause skin infections in rural
    Alaska appears attributable to the selective pressure of antibiotic
    use for drug-resistant strains expressing PVL." In other words,
    antibiotic use selected for more virulent PVL-containing strains of
    MRSA. The more exposure to antibiotics, the more likely a person was
    to have a MRSA skin infection. Ahhh, the judicious use of
    antibiotics issue yet again rears its ugly head in daily clinical
    practice!

**Editorial Comment**

Community-onset/community-acquired MRSA (CO-MRSA) is emerging as a
significant health problem across the nation, and has been extensively
reported in the literature. This paper, although not specifically
related to child health, is relevant and timely. It serves as a reminder
to all of us that antibiotics have real and measurable costs, both from
an individual patient and a public health perspective. Although
antibiotics are indispensable aides in the control of infections, more
use results in more, and measurable, resistance.

CO-MRSA represents a problem of particular concern for Native
communities. Given the prevalence of certain socioeconomic factors, many
AI/AN populations experience a relatively high background rate of skin
infections. Additionally, AI/AN populations tend to experience a greater
burden of deep and invasive infections than the general population.
These and other realities could serve to lower the threshold for
antibiotic use among providers, and translate into additional selective
pressure on microbes within Native communities.

As always, judicious use of antibiotics is warranted. Many of us who
work in Native communities are well positioned to put into practice
rational approaches to antibiotic use, given our inclination toward
public health practice.

In Alaska, given the high prevalence of CO-MRSA, an effort was made on
the part of the CDC Arctic Investigations Program to encourage
appropriate antibiotic use when confronted with suspected Staphylococcal
infections. Efforts were designed to limit the development of inducible
clindamycin resistance among MRSA strains, and to use vancomycin with
the utmost caution. Cotrimoxazole became the first-line antibiotic, used
only if local care of infection was unsuccessful or impracticable.
Although the effect of this effort is unknown, the time is ripe for all
of us to look critically at this issue and develop rational approaches
to antibiotic use for suspected Staphylococcal infections within our own
clinical settings and communities, in an effort to further limit the
development of microbial "super strains."

**Additional Reading**

Community-acquired methicillin-resistant *Staphylococcus aureus* in a
rural American Indian community. *JAMA* 2001;286(10); 1201-5.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11559265&query_hl=5>

Community-acquired methicillin-resistant *Staphylococcus aureus* in
southern New England children. *Pediatrics*. 2004;113(4):347-52.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15060266&query_hl=8>

Community-associated methicillin-resistant *Staphylococcus aureus* in
pediatric patients.\
*Emerg Infect Dis*. 2005 Jun;11(6):966-8.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15963299&query_hl=10>

# 

# [Pediatric Locums Service]{.underline} 

The AAP Committee on Native American Child Health has developed a web
site to help IHS and 638 contract sites find pediatric locums. The web
site has on line form you can fill out describing your locums needs and
which will be posted for AAP members.

[www.aap.org/nach](http://www.aap.org/nach)

In addition, the AAP is interested in helping site find pediatricians to
fill permanent vacancies. Contact AAP staff member Sunnah Kim at
847-434-4729

.