njm 4/1/04

*"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@tcimic.ihs.gov**](mailto:sholve@tcimic.ihs.gov)

IHS Child Health Notes

April 2004

# Quote of the month

*"Never say or use anything you can't spell*."

Will Rogers

# Articles of Interest -- Varicella Vaccine

1\. Reduction in pediatric hospitalizations for varicella-related
invasive group A streptococcal infections in the varicella vaccine era.
J Pediatr. 2004 Jan;144(1):68-74.

[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=%2014722521](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 14722521)

-   30% of pediatric invasive group A strep infections were related to
    chickenpox prior to the introduction of the varicella vaccine in
    1995

-   In the current era of widespread varicella vaccine use only 2% of
    pediatric invasive group A strep infections were secondary to
    chickenpox

-   Oddly, despite the decrease in cases related to varicella, the
    overall rate of hospitalization for invasive group A strep did not
    change from 1995 to 2001

2\. Outbreak of varicella at a day care center despite vaccination NEJM.
2002 Dec 12;347(24)1909-15.

[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=%2012477940](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12477940)

-   Effectiveness was only 44% against any sign/symptoms of chickenpox

-   It was, however, nearly 90% effective at preventing severe disease

-   There was an increased risk of illness if it was \> 3 years from
    varicella vaccination

3\. Younger age at vaccination may increase risk of varicella vaccine
failure. J Infect Dis. 2002 Jul1;186(1) 102-5.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12089668>

-   Vaccine effectiveness was better in this study: 80% against any
    disease and 95% for severe varicella

-   Varicella vaccination at \<14 months of age was associated with a 3
    fold greater risk of breakthrough disease

# Editorial Comment

Geezer pediatricians remember when every child got chickenpox. Despite
what even older geezer pediatricians told us back then, varicella was
not always a benign disease. The first study documents one of the
benefits of vaccination, a reduction in the risk of invasive group A
strep infections. The second and third studies point out one of the
drawbacks of the varicella vaccine. It is effective at preventing severe
varicella disease, but it does not absolutely prevent Chickenpox. The
third study suggests a way to maximize the benefits of varicella vaccine
-- give the dose at \>14 months of age.

In Navajo Area IHS we recently have changed our vaccination schedule so
that the varicella vaccine is given routinely at 15 months to take
advantage of the increased immunogenicity that comes with increased age.
This same approach was taken years ago with the MMR vaccine when the
time of administration was increased from 9 months to 12 months to take
advantage of increased immunogenicity. One caveat -- the MMR and the
varicella vaccines, as live vaccines, must be given at least one month
apart. For further info see the AAP policy statement from 2000 on
varicella at:
<http://aappolicy.aappublications.org/cgi/content/full/pediatrics;105/1/136?maxtoshow=>

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

Vaccination coverage of American Indian/Alaska native children aged 19
to 35 months: findings from the National Immunization Survey, 1998-2000.

Am J Public Health. 2003 Dec;93(12):2046-9.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14652331>

# Despite having several risk factors for under immunization such as low socioeconomic status and large family size AI/AN had immunization rates that were equivalent to that of the U.S. population as a whole. In the 10 states with the largest AI/AN population the immunization rates for AI/AN were actually higher than the non-AI/AN population. The authors speculate that the comprehensive health care system provided by the IHS may account for this excellent showing despite risk for factors for under immunization.

Diabetes among young American Indians\--Montana and Wyoming, 2000-2002.

MMWR Morb Mortal Wkly Rep. 2003 Nov 21;52(46):1127-9.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14627952>

-   As anyone who has used the RPMS system to retrieve data knows, there
    are lots of coding errors. To minimize overcounting patients with
    diabetes this report suggests a patient needs to have at least two
    visits coded under diabetes mellitus to insure the diagnosis is
    reliable.

Childhood cancer among Alaska Natives.

Pediatrics. 2003 Nov;112(5):e396.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14595083>

-   Childhood cancer rates for Alaskan Natives were similar to US whites
    except for hepatocellular cancer, which was 45 times higher in the
    Eskimo. All cases of hepatocellular carcinoma were HbsAg positive.
    Alaska began a statewide hepatitis B vaccine program in 1982. There
    have been no cases of hepatitis B in children born in the past 20
    years. Another example of the power of vaccinations.

# Meetings of Interest for Child Health

Adolescent Health Issues in Indian Health:

School Based Health: Donna Perry, Susie John, and others

Adolescent Issues: Steve Holve and Donna Perry

Sexually Transmitted Diseases, Contraception, and more....

These are all available at the Biennial IHS Tribal and Urban (ITU)
Meeting on Women's Health and Maternity Care, August 4-6, 2004 in
Albuquerque, NM.

<http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#August2004>

Or contact Neil Murphy, MD for info at [nmurphy@anmc.org]{.underline}