*"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 comments contact Steve Holve, MD, Chief
Clinical Consultant in Pediatrics at sholve@tcimc.ihs.gov

IHS Child Health Notes

January 2007

# Quote of the month

*\"A radical is a man with both feet planted firmly in the air. A
conservative is a man with two perfectly good legs, however, who has
never learned to walk forward.\"*

Franklin Roosevelt

**Article of Interest**

Effect of needle size on immunogenicity and reactogenicity of vaccines
in infants: randomized controlled trial.\
BMJ. 2006 Sep 16;333(7568):571.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=search&DB=pubmed>

# Editorial Comment

A cliché is that sometimes "less is more". In this case the British
demonstrate that "more is less" when it comes to needle size and
vaccinations.

Infants receiving intramuscular vaccinations with a long needle (25mm)
had fewer local reactions, and especially had fewer severe local
reactions, when compared with infants vaccinated with a short (16mm)
needle. The width of the needle did not affect the reactogencity and
immune response did not differ between groups.

While we often choose the smallest needle in an effort to decrease pain,
this study suggests that a longer needle may be the better choice to
minimize local reactions after vaccinations.

Editorial Comment

**Infectious Disease Updates**.

Rosalyn Singleton, MD, MPH

Introducing the 2007 Child and Adolescent Immunization Schedule

Here's a simplified version of the 2007 Child and Adolescent
Immunization Schedule -- although there's nothing simple about this
schedule! There are some caveats on each vaccine in the footnotes.

  ------------------- ----------- ------------ ------- ------------ ------------------------------------------------------------- -- ------------ -- --------- ---------- ------------ -------------------
                      **Birth**   **2m**               **4m**       **6m**                                                           **12m**         **15m**   **2yrs**   **4-6yrs**   **11-18yrs**

  **Hep B^1^**        **√**       **√**                             **√**                                                                                                              

  **DTaP^2^**                     **√**        **√**                **√**                                                            **√**                                **√**        **√**Tdap**^10^**

  **IPV^3^**                      **√**        **√**                **√**                                                                                                 **√**        

  **Hib**                         PedvaxHib®           PedvaxHib®                                                                    PedvaxHib®                                        

  **PCV7^4^**                     **√**                **√**        **√**                                                            **√**                                             

  **Rotavirus^5^**                **√**                **√**        **√**                                                                                                              

  **MMR^6^**                                                                                                                         **√**                                **√**        

  **Varicella^6^**                                                                                                                   **√**                                **√**        

  **Hep A^7^**                                                                                                                       **√**                     **√**                   

  **Influenza^8^**                                                  Yearly, 6-59 month                                                                                                 
                                                                    olds\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--                                                        

  **HPV^9^**                                                                                                                                                                           Gardasil®

  **MeningCV4^11^**                                                                                                                                                                    Menactra®
  ------------------- ----------- ------------ ------- ------------ ------------------------------------------------------------- -- ------------ -- --------- ---------- ------------ -------------------

**1 HepB**: First Hep B soon after birth. You may use Pediarix®
(DTaP-IPV-HepB) at 2,4, 6 months or Comvax® (HepB-PedvaxHIB) at 2,4, and
12 months for doses 2, 3, and 4 of Hep B in infants. Final dose must be
[\>]{.underline} 24 weeks of age, at least 8 weeks after dose #2.

**2** **DTaP**: min. age 42 days. Pediarix® can be used for doses 1-3 of
DTaP. Don't use Pediarix® in children [\>]{.underline}7 yrs or for DTaP
4 or 5. DTaP 4 can be given at 12 months if 6 months since dose 3. Don't
need DTaP5 if DTaP4 given after age 4 yrs.

**3** **IPV**: min. 42 days. Pediarix® and be used for doses 1-3 of IPV.
Single antigen IPV, not Pediarix®, must be used for dose 4. Do not need
IPV4 if IPV3 given after age 4.

**4** **Pneumo-conj**. (Prevnar®):min. age 42 days. Give at 2, 4, 6
months with booster [\>]{.underline} 12 months, at least 2 months from
previous dose.

**5** **Rotavirus** (RotaTeq®): min. 42 days. Give dose 1 at 6-12 weeks.
Don't start series if [\>]{.underline}13 weeks. All doses of RotaTeq®
must be given by 32 weeks (8 months) of age.

**6 MMR and Varicella**: 12 months. 2^nd^ MMR and Varicella routine at
4-6 yr, but can be given [\>]{.underline} 4 wks (3 mo for Var -- but
don't need to repeat if [\>]{.underline} 4 weeks) after dose 1.
Varicella dose 2 can be given to Vaccine For Children eligible children
through age 18.

**7** **Hep A**: min.12 months. Can be given as early as 12 months, but
is forecast at 15 months. Two doses of Hep A vaccine are needed at least
6 calendar months apart.

**8 Influenza --** min. age 6 mos. 2 doses first year, 1 dose every year
after for children \<9 years. Routinely immunize 6-59 month olds.

**9 HPV** (Gardasil®): min age 9 yrs. Many states are providing for
11-12 year old girls. 3 dose series at "0", 1, and 6 months.

**10 Tdap** (Adacel®): min. age 11 yrs. all 11-18 year olds
[\>]{.underline}5 years since last Td/DTaP.

**11** **MeningCV4** (Menactra®): 1 dose for 11-12 and 15 year olds and
college freshmen in dorms as well as rare conditions such as asplenia
and terminal complement deficiencies.

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

Doug Esposito, MD

I would like to direct the reader's attention to several excellent
articles in the December issue of the *American Journal of Public
Health*. This entire issue is devoted to "Embracing a Common Destiny:
Health for All." It is impossible not to be consumed by the subjects of
health disparities and inequities in access to health care when
considering issues facing Native American and First Nations populations
in North America. As regular readers of this column know, the thrust of
my comments have centered on these topics since I began writing for Dr.
Holve nearly one and a half years ago. Imagine my excitement whenever I
come across an entire journal issue devoted to Health for All!

**[Article]{.underline}**

Health and health care for the 21st century: for all the people. *Am J
Public Health*. 2006 Dec;96(12):2090-2. Epub 2006 Oct 31.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17077403&query_hl=1&itool=pubmed_docsum>

**Editorial Comment**

The December issue of the *American Journal of Public Health* begins
with this excellent editorial by the much celebrated former Surgeon
General of the United States, Dr. C. Everett Koop. Just to set the tone,
here is a wonderful quote by this dedicated and outspoken public health
advocate and leader: "Our capability to prevent and treat disease seems
to exceed our willingness to apply our interventions." Truer (and
sadder) words have not been written on the subject! We certainly have
the technological and economic means to advance the health status of
every American to a point far beyond the current level. The only thing
lacking is the resolve. Dr. Koop further elaborates: "I am concerned,
however, that the difference between the "haves" and the "have-nots"
will worsen. It is in vogue to blame problems on the victims of disease
and disability, on laziness, on immigration, on those who hold opposing
political points of view, or even---and perhaps most incredibly in this
most wealthy of all nations---on lack of resources. Consider just 2
telling facts: 80% of people without health insurance are from working
families and nearly 20% of them are children. Can we blame their lack of
access to health care on them?"

**[Article]{.underline}**

The persistence of American Indian health disparities. *Am J Public
Health*. 2006 Dec;96(12):2122-34. Epub 2006 Oct 31.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17077399&query_hl=1&itool=pubmed_DocSum>

**Summary and Editorial Comment**

This paper chronicles the 500-year history of health disparities for
American Indian populations. It explores the diverse explanations
proposed over time that have been used to rationalize, and sometimes
address, the presence and persistence of these disparities. Beginning
with theories of providence of God and working through to more
contemporary ideas emphasizing environment, behavior, biology, and
socioeconomics, the author takes the reader on a wonderful
post-Columbian journey, presenting a novel, interesting, and important
approach to answering some key contemporary questions. "Do American
Indians have intrinsic susceptibilities to every disease for which
disparities have existed? Or does the history of disparity after
disparity suggest that social and economic conditions have played a more
powerful role in generating Indian vulnerability to disease?" Yet again,
the issue of biology vs. society rears its ugly head (please see the
"Additional Reading" section below)!

In reading this article, I wonder how far we really have come since the
late 1800s; "Medical campaigns, for example, suffered from inadequate
funding. Commissioner of Indian Affairs T. J. Morgan compared the
salaries paid to government physicians in the Army, Navy, and IHS and
divided these sums by the populations served. He then calculated a crude
estimate of how the government valued people: \$21.91 per soldier,
\$48.10 per sailor, and \$1.25 per Indian." Now, doesn't this sound
frighteningly similar to contemporary estimates of disparities in per
capita health expenditures? As reported in a study done by the United
States Commission on Civil Rights in April 2004: "HHS estimates the FY
2003 annual per capita health care spending for the general population
at \$5,065. In contrast, IHS spent \$1,914 per eligible user, or 38
percent of that spent by the general population." What rightfully stirs
the ire of Native Americans, though, is this: the U.S. spends \$3,803
per year per federal prisoner, almost twice as much as it spends for an
American Indian or Alaska Native. Ouch!!

I believe it is absolutely critical for our society to acknowledge and
come to grips with the true etiology of the health disparities endured
by minority populations. Society needs to take responsibility for the
existence of these deplorable realities. The fallacy that there exists a
real biologic cause, conveniently reflected by skin color and body
habitus alone, only serves to divert attention away from the true
problem; that being disparities in wealth and power, or more simply,
racism and unequal access and opportunity. But please, don't take my
word for it, go to the article and deliberate for yourselves\...then
let's all work together as a society on a solution!

**Additional Reading**

On the issue of genomics, please see the March 2006 issue of the *IHS
Child Health Notes* on Race, Genetics, and the Biologic Versus Social
Determinants of Health and Health Disparities:
<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN306.doc>

Broken Promises: Evaluating the Native American Health Care System. U.S.
Commission on Civil Rights, April 2004.
<http://www.usccr.gov/pubs/nahealth/nabroken.pdf>

**[Article]{.underline}**

Infant mortality trends and differences between American Indian/Alaska
Native infants and white infants in the United States, 1989-1991 and
1998-2000. *Am J Public Health*. 2006 Dec;96(12):2222-7. Epub 2006 Oct
31.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17077400&query_hl=1&itool=pubmed_DocSum>

**Summary and Editorial Comment**

In another article highlighting the "Health for All" theme, this study
offers a detailed analysis of measurable disparities in infant and
neonatal mortality suffered by Native Americans. In the October issue of
the *IHS Child Health Notes*, I discussed an *MMWR QuickStats* showing
that infant mortality for American Indian/Alaska Native mothers ranks
second highest in the U.S., surpassed only by the rate for non-Hispanic
blacks. The paper appearing in the December issue of the *American
Journal of Public Health* is a much more detailed and relevant analysis.

The authors analyzed linked birth/infant-death data in order to generate
birthweight-specific and cause-specific neonatal and infant mortality
rates for white and AI/AN infants born at ≥20 weeks' gestation in the
U.S. in 1989-1991 compared with 1998-2000. Although some definite and
significant gains have been made over the period, presumably preventable
disparities still do exist. Of note is that decreases in disparities
between AI/AN and White infants were identified in some measures while
increases were found in others.

On a slightly more cheery note, the authors found that AI/AN infant
mortality overall was only 1.7 times that of White infants. This
compares favorably with historical data. Infant mortality rates once
were several-fold higher for Native Americans than for the general U.S.
population. However, although real progress has been made, it has been
impossibly (and perhaps unforgivably) slow. As a result of the disparity
in infant mortality, countless and needless infant deaths have occurred
over the centuries exacting a terrible toll on the wellbeing of the
afflicted populations through chronic, unrelenting emotional trauma.
This situation will certainly have a lasting negative impact that can be
expected to persist perhaps generations beyond the time the disparity is
finally eliminated.

The authors offer a very thoughtful analysis of the troubles and the
achievements in infant mortality over a ten-year period. This article is
well worth a look by any practitioner delivering care to AI/AN infants
or by anyone seeking to assist in the reduction and eventual elimination
of health disparities for this population.

**Additional Reading**

October 2006 issue of the *IHS Child Health Notes*:
<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN1006.doc>

**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>

.