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

Deng Hsaio P'ing

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 steve.holve@tchealth.org

IHS Child Health Notes

September 2008

# Quote of the month

*"My country right or wrong is something no true patriot would say...It
is like saying, 'My mother, drunk or sober'"*"

G. K. Chesterton

# Article of Interest

# Prevention and Control of Influenza 

Recommendations of the Advisory Committee on Immunization Practices
(ACIP)

July 17, 2008 (Early Release);1-60

<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr57e717a1.htm>

This report updates the 2007 recommendations by CDC\'s Advisory
Committee on Immunization Practices (ACIP) regarding the use of
influenza vaccine and antiviral agents. Principal updates and changes
include 1) a new recommendation that annual vaccination be administered
to all children aged 5\--18 years, beginning in the 2008\--09 influenza
season, if feasible, but no later than the 2009\--10 influenza season;
2) a recommendation that annual vaccination of all children aged 6
months through 4 years (59 months) continue to be a primary focus of
vaccination efforts because these children are at higher risk for
influenza complications compared with older children; 3) a new
recommendation that either trivalent inactivated influenza vaccine or
live, attenuated influenza vaccine (LAIV) be used when vaccinating
healthy persons aged 2 through 49 years (the previous recommendation was
to administer LAIV to person aged 5\--49 years 

The age at which LAIV can be administered has been expanded include
children ages 2- 5 years of age. LAIV can be administered to persons
with minor acute illnesses (e.g., diarrhea or mild upper respiratory
tract infection with or without fever). However, if nasal congestion is
present that might impede delivery of the vaccine to the mucosa,
deferral of administration should be considered until resolution of the
illness.

**The effectiveness or safety of LAIV is not known for the following
groups, and these persons should not be vaccinated with LAIV:**

-   persons with a history of hypersensitivity, including anaphylaxis,
    to any of the components of LAIV or to eggs.

-   persons aged \<2 years or those aged [\>]{.underline}50 years;

-   persons with any of the underlying medical conditions that serve as
    an indication for routine influenza vaccination, including asthma,
    reactive airways disease, or other chronic disorders of the
    pulmonary or cardiovascular systems; other underlying medical
    conditions, including such metabolic diseases as diabetes, renal
    dysfunction, and hemoglobinopathies; or known or suspected
    immunodeficiency diseases or immunosuppressed states;

-   children aged 2\--4 years whose parents or caregivers report that a
    health-care provider has told them during the preceding 12 months
    that their child had wheezing or asthma, or whose medical record
    indicates a wheezing episode has occurred during the preceding 12
    months;

-   children or adolescents receiving aspirin or other salicylates
    (because of the association of Reye syndrome with wild-type
    influenza virus infection);

-   persons with a history of GBS after influenza vaccination; or

-   pregnant women.

**Editorial Comment**

These latest recommendations from ACIP make flu vaccination nearly
universal. For those caring for children this means that the VFC program
will cover flu vaccine for all children ages 6 months through 18 years.
They also expand the use of LAIV to children between the ages of 2 to 5
years and practitioners may wish to consider the use of LAIV in this age
group. Practitioners may wish to consider alternative ways of delivering
vaccine to their patients; this could include walk-in flu vaccine
clinics and the use of schools or community centers outside of usual
health care settings to administer flu vaccines.

A model school program is described in this article:

A pilot study of the effectiveness of a school-based influenza
vaccination program.

Pediatrics. 2005 Dec;116(6):e868-73.

**Infectious Disease Updates**.

Rosalyn Singleton, MD

***Rotavirus activity decreased in the U.S. in 2007-8***

Rotavirus is the leading cause of severe acute gastroenteritis among
infants and young children, accounting for an estimated 55,000\--70,000
hospitalizations and 250,000 emergency department visits in the United
States annually. In winter months, approximately 50% of hospitalizations
and ED visits and 30% of outpatient visits for acute gastroenteritis
among children aged \<3 years are caused by rotavirus. In February 2006,
a human-bovine rotavirus vaccine, RotaTeq^®^ (RV5, rota-pentavalent,
Merck & Co., Inc.) was recommended for routine use among U.S. infants.
To summarize rotavirus activity during the 2007\--08 season, CDC
analyzed data from the National Respiratory and Enteric Virus
Surveillance System and New Vaccine Surveillance Network. When compared
with the 15 previous seasons spanning 1991\--2006, rotavirus activity
during the current season appeared delayed in onset by 2\--4 months and
diminished in magnitude by \>50%.

***Rotarix® licensed in the U.S.***

A new rotavirus vaccine (Rotarix®, RV1, rota-monovalent,
GlaxoSmithKline) was licensed on April 3, 2008. On June 25, 2008, the
ACIP voted on new recommendations for the use of rotavirus vaccine:
<http://www.cdc.gvo/vaccines/recs/provisional/downloads/rota-7-1-08-508.pdf>

[Routine administration]{.underline}

-   RotaTeq (rota-pent) is a 3-dose series recommended at 2, 4, and 6
    months of age

-   Rotarix® (rota-mono) is a 2-dose series recommended at 2 and 4
    months of age

-   The first dose of either vaccine should be administered between age
    6 weeks and age 14 weeks 6 days (new maximum age of first dose)

-   Minimum interval between each dose is 4 weeks

-   All doses should be administered by age 8 months 0 days.

[Interchangeability of Rotavirus vaccines]{.underline}

-   ACIP prefers completion of series with same vaccine, but any
    combination of 3 doses is allowed.

[Contraindications]{.underline}

-   History of anaphylaxis after previous dose or vaccine component.

-   Latex rubber is contained in Rotarix® (rota-mono) applicator --
    infants with anaphylactic allergy to latex should not receive
    Rotarix®

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

Michael L. Bartholomew, MD

Rutman S., Park A, Castor M, ATaualii M, Forquera R. Urban American
Indian and Alaska Native Youth: Youth Risk Behavior Survey 1997-2003.
*Matern Child Health J.* 2008 May 16. \[Epub ahead of print\]

http://www.ncbi.nlm.nih.gov/pubmed/18483839?ordinalpos=4&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

Studies to date of American Indian and Alaska Native (AI/AN) youth
behavior and health status tend to focus on non-urban youths. Studies
that specifically address urban Indians tend to be regionally specific
and their results can not be extrapolated to a national level^1^. The
number of AI/AN people living in urban areas continues to grow. In the
2000 U.S. Census, 2.8 million of the 4.1 million persons reporting AI/AN
race resided in urban areas. With a large percentage of this population
being less than 18 years, it is important to understand and examine the
health status and health behaviors of this group.

The purpose of this study is to identify and examine the health risk
behaviors in urban AI/AN youth by analyzing aggregate data from 4 survey
years (1997, 1999, 2001, 2003) of the YRBS.

The Youth Risk Behavior Survey (YRBS) is a self reported questionnaire
administered to high school students (grades 9-12) biennially by the
Centers for Disease Control and Prevention (CDC) to monitor the health
risk behaviors. The survey divides behaviors that lead to morbidity and
mortality in 6 risk areas: behaviors that result in unintentional
injuries and violence; tobacco use; alcohol and drug use, behaviors that
contribute to unintended pregnancy and sexually transmitted diseases;
physical inactivity; and dietary behaviors including weight status.

Of the behaviors that measure unintentional injury, safety, and
violence, eleven of the sixteen measures were found to be higher in
urban AI/AN youth than white youth including school-related safety and
violence. Urban AI/AN youth were more likely to be in a physical fight,
requiring medical treatment for injuries related to a physical fight,
physically hurt by a boy/girlfriend, physically forced to have unwanted
sex, carrying a weapon in the past year and carrying a gun in the past
month. Of the 5 suicidal ideation and related behavior measurements,
four were higher in the urban AI/AN youth than their white counterparts
including attempted suicide (threefold higher) and injury from suicide
attempt (fivefold higher).

In regards to tobacco use only 2 of the 16 measures were significantly
higher in the AI/AN youth: smoking a cigarette before age 13 (33.1% vs.
18.4%) and smoking cigarettes at school in the last month (20.7% vs.
12.9%).

AI/AN youth were more likely to have consumed alcohol prior to age 13
and have had alcohol at school in the past month. Of the 15 questions
addressing illegal drug use (including marijuana, cocaine, heroin,
steroids, and injection drugs), AI/AN youth had higher reported use than
there white counterparts. There was no difference between AI/AN and
white youth in the reported use (lifetime or current) of glue,
methamphetamines, hallucinogens and ecstasy.

American Indian/Alaska Native youth had a higher percentage sexual
intercourse, first sexual intercourse before age 13, sexual intercourse
with multiple partners (\>4), sexual intercourse with greater than or
equal to 1 person in the past three months and having been pregnant or
making someone pregnant.

Lastly, in regards to physical activity and dietary behaviors, urban
AI/AN adolescents watched at least 3 hours of television on an average
school day (45.1% AI/AN vs. 31.7% white) and 38.7% of urban AI/AN youth
described themselves as slightly or very overweight as compared to 28.8%
of white youth.

The authors cite five limitations to their study. First, there were
small numbers of AI/AN in the study (513 AI/AN youths of the 52,364
urban sample), thus making trend analysis difficult. Second, YRBS
questions have not been validated on AI/AN populations, allowing for
interpretation of the questions to possibly affect the responses. Third,
underreporting of unhealthy behaviors (illegal drug use, alcohol
consumption) and over-reporting of healthy behaviors such as exercise
may occur in self-reported surveys. Fourth, the survey is not
representative to each metropolitan area thus making generalizations of
the results unreliable. Lastly, the results are of those youth that
attend school and does not taking into account high school dropouts,
thus possibly underestimating the prevalence of high-risk behaviors.

Few studies explore the health status of urban AI/AN youth on a national
level. Most studies focus solely on AI/AN youth that reside on
reservations or rural areas of the country. This study illustrates the
high-risk health behaviors that are specific to urban AI/AN youth. By
identifying and focusing on these behaviors, health promotion and
disease prevention programs as well as intervention programs can be
tailored to address the needs of this population.

Additional information and resources on Urban Indian Health:

1.  Indian Health Service: Urban Health Programs.
    <http://www.ihs.gov/NonMedicalPrograms/Urban/Urban_index.asp>

2.  National Council of Urban Indian Health.
    <http://www.ncuih.org/index.html>

3.  Urban Indian Health Institute. <http://www.uihi.org/>

Reference:

> 1\. Dixon, M, Roubideaux,Y (2001). *Promises to Keep: Public Health
> Policy for American Indians & Alaska Natives n the 21st Century*.
> Washington D.C.: American Public Health Association. 121-134.

**Special Announcement**

**CDC -TV  is currently making the soon to be released animated version
of all 4 Eagle Books  available for  viewing on the internet at 
[[http://www.cdc.gov/CDCTV/]{.underline}](http://www.cdc.gov/CDCTV/) **

 

The animated version of the Eagle Book series (Through the Eyes of the
Eagle, Knees Lifted High, Plate Full of Color, and Tricky Treats) has
been created for availability on DVD from the Native Diabetes Wellness
Program (NDWP), Division of Diabetes Translation (DDT), Centers for
Disease Control and Prevention (CDC).

 

The full featured DVD can be used in many ways as an interactive tool
with parents, teachers and communities to engage children in activities
and discussions about healthy eating and the joy of being active while
looking to traditional ways to stay healthy and prevent type 2 diabetes.

The author of the original Eagle Books, Georgia Perez, provides the
narration for the animated videos. Children and adults from the Standing
Rock Sioux tribal nation bring the book characters alive with their
creative voice talent. The DVD has many special features including:

-   Three American Indian language translations of the books (Chickasaw,
    Paiute, Shoshone)

-   Spanish translations

-   Closed Captioning (CC) and Video Descriptions (for the Deaf/Hard of
    Hearing/Blind and Visually Impaired)

-   Information about the author and illustrators

-   Resources for children, parents, teachers and communities

To assist teachers and parents the DVD can be stopped and started for
listening to elders, demonstrating fun ways to be active, describing the
many colored fruits and vegetables from Mother Earth, and deciding what
is a "sometimes" or "everyday" food selection. Teachers and parents may
also find the DVD can be used as a read-along tool to accompany
the print copies of the Eagle Books.

 

Join the fun and watch the Eagle Books characters and beautiful artwork
by Patrick Rolo and Lisa Fifeild come alive on the DVD and the internet
today. 

 

If you have questions about the animation please contact Cherryll Ranger
<chr4@cdc.gov>