Immunization in the real world, ADHD: Looking for consensus, Teens and STDs, Get your application kit now, How good is your health plan? R is for Risk groups; Eye on Washington
Every January, the Advisory Committee on Immunization Practices (ACIP)and the American Academy of Pediatrics tell pediatricians which immunizationschildren should get routinely and when they should get them; you'll findthis year's recommendations in the Special Report on pages 30 and 31. Butwhat really matters for children is not so much what the experts recommendas what physicians and clinics actually do. Two new studies shed light onhow some controversial recommendations are working out in practice:
Varicella immunization. Four years ago, when this vaccine was first addedto the schedule, some physicians and parents were skeptical. Chickenpoxwas a normal part of childhood, they said, and nature should be allowedto take its course. But according to a new survey from the American Academyof Pediatrics, many of the skeptics have been won over; 69% of AAP membersoffer the vaccine to all or nearly all of their patients, 14% provide itto "some," and only 17% to "few or none." The holdoutsare concentrated in inner city and rural areas. Practices with a high proportionof Medicaid patients were less likely to provide the vaccine, and thosewith a high proportion of patients in managed care were more likely to doso. Experts at the Centers for Disease Control and Prevention have provideda Q and A that will help you answer parents' questions about varicella vaccine;you can find it at www.immunize.org, the website of the Immunization ActionCoalition.
Replacing OPV with IPV. Last year, when the ACIP suggested replacingthe first two doses of oral polio vaccine with inactivated vaccine, oppositionto the change centered on compliance. Parents wouldn't want to subject theirchildren to additional shots, the argument went, and the net result wouldbe an overall drop in immunization rates. Now the CDC has tested that propositionand found that, in two very large HMO populations on the West Coast, itdoesn't hold. In a 1997 study of children enrolled in Group Health Cooperativeof Puget Sound and Kaiser Permanente of Northern California, the CDC foundsteady, rapid increases in the percentage of children whose first polioimmunization was IPV and did not find any decrease in overall vaccinationcoverage (MMWR 1998; 47:1017). The finding bodes well for implementationof the IPV recommendations in this year's immunization schedule.
If scientists at the National Institutes of Health hoped that last month'sconsensus development conference on attention deficit hyperactivity disorder(ADHD) would put an end to the controversies that surround this subject,they were disappointed. Definitive answers were not to be found. Confereescould not verify the parameters that define the disorder (although theyagree it exists and poses significant problems); they haven't come up witha reliable diagnostic test (although theyagree, pretty much, on the elementsof a proper evaluation); and they don't know whether treatment that worksin the short term produces long-term improvements.
The conference did present illuminating data on diagnostic and treatmentpractices and on barriers to care. Primary care physicians, studies show,are more likely than developmental pediatricians and psychiatrists to prescribestimulant medications; they also spend less time than specialists do inmaking the diagnosis. Overdiagnosis and underdiagnosis are both common.There is an unfortunate disconnect between educational and medical approachesto the disorder, with damaging failures to communicate between the two domains.Finally, significant barriers to appropriate diagnosis and treatment exist.Insurance coverage for neuropsychological evaluations, behavior modificationprograms, and school consultations is often lacking, with the result thatmedications are covered while more comprehensive approaches are not. Noris ADHD a diagnosis that qualifies a child for federally funded specialeducation, so that school systems are reluctant to provide needed educationalinterventions. Guidelines under development at the American Academy of Pediatricsmay help perplexed pediatricians understand this complex disorder, and continuingefforts to work with insurers and school systems may lead to more comprehensivetreatment.
At a CDC conference last month called Tracing the Hidden Epidemic, epidemiologistsreported progress and defeats in attempts to reduce rates of sexually transmitteddisease in adolescents. Overall, rates of gonorrhea, syphilis, hepatitisB, and chancroid are declining among teens, although rates remain stubbornlyhigh among minorities, in inner cities, and in the South. Chlamydia is amixed picture, declining in areas where screening and treatment are providedin family planning clinics and school-based programs, but stable or increasingwhere these services are not available. Map, above, shows state by statevariations in Chlamydia prevalence. In the Northwest, where large-scalescreening efforts were initiated in 1988, the proportion of women infectedwith Chlamydia has declined by 67%; similar trends are now evident in otherregions that have recently initiated screening and treatment programs.
A major reason for the persistence of high levels of Chlamydia is ignorance;studies presented at the conference show that teens lack accurate informationabout how to prevent infection, and that many pediatricians in private practiceare unaware of their patients' risk and not doing routine tests. "Itis unconscionable that diseases that can be cured with one dose of antibioticscontinue to exact such a tremendous toll," Judith Wasserheit, MD, Directorof the Division of STD Prevention, told attendees. "We simply mustreach people with the prevention, screening, and treatment needed to reducethis toll."
The Healthy Tomorrows Partnership for Children Program (HTPCP) has startedits new funding cycle. Readers who have a good idea for a community healthprogram are encouraged to apply. Federal grants awarded through this programsupport family-centered, community-based health initiatives that improvethe health status of mothers, infants, children, and adolescents by increasingtheir access to health services. If your project gets a grant, you can receiveup to $50,000 a year for five years; applicants must show they can secureadditional funds for the second and sequential years of the project. TheHTPCP is a collaborative venture of the Maternal and Child Health Bureauand the American Academy of Pediatrics. Application kits are available fromthe Grants Application Center of the Health Resources Services Administration;call 888-333-4722 or E-mail email@example.com, and request applicationnumber 93.11OV. For more information about the program, contact Jane Bassewitz,Program Manager, AAP Division of Community Based Initiatives, at 800-433-9016,extension 6750, or send an E-mail to firstname.lastname@example.org.
It's a good question, for physicians and consumers alike, but the answeris hard to find. This year's assessment by the National Committee for QualityAssurance (NCQA) yields two good clues:
Overall, this year's NCQA assessment shows little improvement over theyear before. For example, adolescent immunization rates--one of the study'sselected quality measures--inched ahead by a hair, from 51.5% in 1996 to52.2% in 1997; that still leaves close to half of the teens served by theplans in the survey inadequately immunized. The biggest improvement camein physician involvement in smoking cessation; the portion of physiciansadvising patients to quit went from 61% in 1996 to 64% in 1997. Plans variedwidely on key measures of clinical care, customer service, and member satisfaction.
The really disturbing development, according to NCQA, is the large numberof plans (115 out of 450 surveyed) that refused to allow their scores tobe made public. Not surprisingly, the plans with high scores were more willingto have their scores revealed. If you'd like to read the report for yourself,you'll find it on the web at www.ncqa.org.
Allergic reactions to latex can be life threatening. To spot childrenat risk, suggests Pediatric Nurse Practitioner Ellen V. Meeropol, use theRUBBER acrostic as a screening device (J PediatrHealth Care 1998; November/December:320):
R is for Risk groups:Children with spina bifida, genitourinaryanomalies, cerebral palsy, shunts, asthma, eczema,or food allergies--especiallybanana, kiwi, avocado, potato, or tomato
U is for Unexplained problems during surgery
B is for Breathing difficulties at the dentist's office
B is for Balloons that cause swelling or wheezing
E is for Early surgery, under 1 year of age
R is for Repeated latex exposures, from surgery and bladderor bowel programs.
Any positive response to the RUBBER screen should trigger suspicion.Once a diagnosis of latex allergy is made, the condition should be documentedin all medical, dental, and school records and communicated to all the child'scaregivers. Additional information on latex allergy and alternative productscan be found at www.latexallergyhelp.com.
February 56, Reducing Firearm Injuries: HELP Network National Conference,San Francisco, CA. Contact Marthy Witwer, Children's Memorial Hospital,773-880-3826
February 1015, International Congress on Tropical Pediatrics, Jaipur,India. Contact Dr. Ashok Gupta, Congress Secretariat, at 011-91-141-606060
February 25March 3, American Academy of Allergy, Asthma, and ImmunologyAnnual Meeting, Orlando, FL. Contact the Academy at 414-272-6071 or Eemail@example.com
March 1721, Society for Adolescent Medicine Annual Meeting, LosAngeles, CA. Contact program coordinator, 816-224-8010
March 2628, From Birth to Maturity: A Celebration of Pediatric Pulmonology,Orlando, FL. Call 800-433-9016, extension 7657 or 4997
March 2830, Conference on Vaccine Research, Bethesda, MD. Call NIHconference coordinator, 301-656-0003, extension 19. h
December in the capital was a gray month, with a lame duck Congress occupiedwith the only matter of importance before them: the possible impeachmentof the President. While the old Congress was thus occupied and the newlyelected Congress not yet sworn in, governmental action on child health andwelfare issues was relegated to the executive agencies.
The Food and Drug Administration, having tried volunteerism and the lureof additional patent protection with minimal success, issued new regulationsmandating testing of new drugs and vaccines in children. The new rules applyto products that are "likely to be used in a substantial number ofpediatric patients" or provide a "meaningful therapeutic benefit"for children when compared to existing therapies. In some situations, newdrugs may win approval for adult use with a requirement for subsequent testingin children. Companies may be exempt from these requirements if pediatricstudies would be impossible or highly impractical, or would pose undue risks.
The Department of Agriculture added a health insurance check-off boxto the application families fill out to qualify for free and reduced-priceschool lunches, as part of an Administration-wide effort to identify childreneligible for Medicaid or the new state child health insurance programs (SCHIP).As part of the same effort, the Department of Housing and Urban Development(HUD) will seek help in enrolling eligible children from managers of publichousing authorities, and the Treasury Department will ask employees whodeal with the earned income tax credit program to inform low-income familiesof their children's possible eligibility.
The Environmental Protection Agency (EPA) issued two new water-qualitystandards, one requiring communities to upgrade water filtration systemsto remove more disease-causing organisms like Cryptosporidium and the othersetting stricter standards for the use of chlorine and other disinfectantsthat have been shown to cause cancer in laboratory animals.
The Consumer Product Safety Commission requested that manufacturers removea chemical called DINP used to soften vinyl from baby rattles and teethersbecause the substance has been shown to cause liver damage in laboratoryanimals. Parents were advised to throw away vinyl nipples and pacifiers,but the Commission declined to restrict use of the chemical in toys. Inanother action, the Commission urged parents to repair or get rid of foldingmesh playpens with protruding rivets that can catch pacifier strings orclothing; eight toddlers have died of strangulation in such playpens overthe last 15 years. The brands involved are Bilt-Rite, Evenflo, Gerry, Graco,Kolcraft, Playskool, Pride-Trimble, and Strolee.
UPDATES. Contemporary Pediatrics 1999;0:013.