The Pediatric Infectious Disease Journal® Newsletter (1998)

ADDENDUM In the September 1998 Newsletter we congratulated Stan Block, M.D. for receiving the 1998 AAP Practitioner Research Award and compared his fine work with that of two noteworthy predecessors, Burtis Breese and Maxwell Stillerman. We learned recently that Doctors Breese and Stillerman died within the past several months. Both physicians made monumental contributions to our knowledge of the natural history and management of group A streptococcal pharyngitis and to other areas as well. They were the pioneers of office-based pediatric infectious disease research and both established standards that only a few practitioners have subsequently equaled. We hope that there are residents and fellows who will be inspired to follow in their footsteps. TB IN DAY-CARE An outbreak of tuberculosis in day-care is unusual and, when it does occur, the source case is usually an adult. Not so for an outbreak reported recently by the health department in Austin-Travis County, Texas. In 1997 the index case, a 10 month old boy, was diagnosed with pulmonary TB after 4 months of bronchilator nebulizer treatments given by the day-care home personnel for alleged asthma. Four additional children in the home developed acute tuberculosis and four others had positive skin tests only. Two adult family members, the day-care home owner and the index case's father, had positive tuberculin reactions without evidence of disease. The isolates from the index case, the source case (a friend of the index case's mother who visited the home several times) and three other pediatric cases in the home had the same DNA fingerprinting patterns indicating the organism was identical in all. It was speculated that nebulizer treatment in the index case provided the opportunity for spread of the organism within the day-care home. The Red Book states, "Since children with primary tuberculosis are usually not contagious, their contacts are not likely to be infected unless they have been in contact with the same adult source." Episodes like this day-care outbreak are prime examples of why The Red Book Committee uses qualifying adverbs such as "usually" and "not likely" in its pronouncements. ROTAVIRUS VACCINE APPROVED On August 31, 1998 the Food and Drug Administration approved a tetravalent rotavirus vaccine (RotaShield®, Wyeth-Ayerst Laboratories) for oral administration at 2, 4 and 6 months of age. The rhesus-human reassortant vaccine is about 50% effective in preventing any rotavirus-associated diarrhea and up to 90% effective in preventing severe diarrhea. It is well tolerated and can be coadministered with oral polio vaccine. Fever greater than 38°C occurs in approximately 15% of recipients, most commonly after the first dose. The vaccine was not approved for infants and children older than 6 months. The purchase price to physicians is $38 for each dose. ENTEROVIRUS 71 INFECTION During April to July 1998 there were approximately 90,000 cases of hand, foot and mouth disease reported by passive surveillance in Taiwan (MMWR 1998;47:629). Of these, 320 children were hospitalized with suspected meningitis, encephalitis or acute flaccid paralysis and at least 55 have died. The illnesses in these latter children, 80% of whom were less than 3 years of age, were characterized by fever and rash, followed 2 to 7 days later by rapid development of cardiopulmonary failure and loss of consciousness. Enterovirus 71 was identified in CNS tissue of one child and isolated from 14 other patients. This is the third recognized outbreak caused by this virus that has caused rapid clinical deterioration and death in young children. The other two occurred in Bulgaria in May-September 1975 and in Malaysia in April-June 1997. The cause for the high case-fatality rates in these outbreaks is the subject of intensive investigations. TICKS AND PREGNANCY From Westchester County NY comes a report of perinatal transmission of the agent of human granulocytic erhlichiosis (New Engl J Med 1998;339:375). The mother became ill on the day of delivery and the infant 8 days later. Both were treated with doxycycline and recovered. Lyme disease, another condition acquired by tick bite, has also caused intrauterine infection. The authors of the HGE article raise the issue of whether a pregnant woman bitten by a tick should receive prophylactic doxycline. (Everyone agrees that it is not indicated for tick bites in non-pregnant individuals.) Why do they even raise the issue? The risk is not quantifiable, but must be very low, and it is not known whether giving the drug to a pregnant woman would prevent infection of her fetus. And does one want to give a tetracycline to a pregnant woman? TRIVIA OF THE MONTH What was the first medical journal published in the United States? The answer: The Medical Repository which was published quarterly from 1797 to 1824. It was printed by T. & J. Swords, Printers to the Faculty of Physic of Columbia College in New York City. The original editors were Samuel Latham Mitchill, Elihu Hubbard Smith and Edward Miller. So, now you know. THE READERS WRITE In the July 1998 Newsletter we railed against the common usage of "disease" instead of "syndrome" in the condition named for Dr. Kawasaki. An expert on the illness, Stanford T. Shulman of Children's Memorial Hospital, Chicago, wrote to us: Of course your assessment is correct that Kawasakisyndromeis technically more accurate than Kawasaki disease.The reason that we have utilized the latter consistently in our writings relates to the Japanese term. In Japanese the symbols for this disorder translate (apparently) to "Kawasaki disease". My inquiries of Dr. Tomisaku Kawasaki regarding this have elicited the response that the Japanese symbol for syndrome is too complex for routine use. Thus, in Japanese this illness is always referred to as Kawasaki disease, and we have chosen to be faithful to that term (except when editors have insisted otherwise). The last parenthetical comment by Dr. Shulman is a little dig at us, which we accept with the good humor he intended (we think). AIDS AND BREAST FEEDING Women infected with HIV can transmit it to their infants via breast milk. Most women living in underdeveloped countries where HIV infection is rampant do not know that they are infected. Breast milk is the best and safest milk for infants. Formula milks are expensive and often reconstituted with dirty water. Until recently the foregoing facts have led experts to recommend that the benefits of breast milk outweigh the risks. Re-examination of the pros and cons has now led the World Health Organization to a change in policy. They estimate that one million babies have become infected from breast milk since 1992. Infected women who choose not to breast feed are encouraged to use safely prepared formula, cow's milk or goat's milk. The WHO is clearly challenging governments to provide safe alternatives to breast milk for their people. This may work for women known to be infected, but what about the many more who are infected and do not know it? This is a dilemma with no easy solution. FLU VACCINE At this time of year we customarily remind you to vaccinate yourselves, hospital and medical office personnel and eligible patients with influenza vaccine. Today our hospital pharmacy was informed that there is a shortage of flu vaccines available from manufacturers. We hope that it is a short lived shortage.