Archives for January 2018

Influenza 2017-18

Leonard Krilov, MD, FAAP

Leonard Krilov, MD, FAAP

Asif Noor, MD, FAAP

Asif Noor, MD, FAAP

Influenza outbreaks are unpredictable.  This year’s flu season has hit the entire country hard.  Influenza activity spiked earlier than expected this year.  It is widespread and already associated with 37 pediatric deaths nationwide.  Over the past month newsflashes of healthy children succumbing to flu are depicting an alarming situation.  The impact is comparable to the 2009 H1N1 Pandemic in terms of its rampant spread.

As a pediatrician you play a crucial role during such an outbreak.  Not only do you treat the flu stricken children, you transform into an advocate for flu prevention through vaccination.  In this blog we address the two common issues faced by the pediatricians, i) understanding the effectiveness of this year’s flu vaccine, and ii) when to consider oseltamivir for treatment.

What are the circulating strains in New York State?  Influenza virus belongs to the orthomyxoviridae family and has two clinically significant antigenic types: influenza A and B.  Influenza A is further subtyped based on the nature of surface proteins, the hemagglutinin (HA) and neuraminidase (NA) which are spike-like projections from the surface.  Genetic mutations in the HA antigen and to a lesser extent NA antigen are responsible for the severity and epidemic potential of outbreaks.  This season the main circulating strain is influenza A H3N2 (77%), followed by H1N1 (15%), and influenza B (8%) based on testing at the New York State Department of Health, Wadsworth Center.

What strains are in the flu vaccine?  The composition of the flu vaccine is reviewed annually and updated based on the circulating influenza strains.  Influenza vaccine for this season includes: A/Michigan/45/2015 (H1N1)pdm09-like virus, A/Hong Kong/4801/2014 (H3N2)-like virus, and B/Brisbane/60/2008-like virus.  The quadrivalent vaccine containing two influenza B viruses contain the above three viruses and a B/Phuket/3073/2013-like virus.

How is the effectiveness of flu vaccine measured?  The effectiveness of the flu vaccine depends upon the match between the vaccine strain and the circulating strain.  The estimate is, however, calculated by the number of cases prevented by the flu vaccine.  This year the circulating H3N2 strain is similar to last year’s strain and is included in the vaccine.  The reason H3N2 strain is still the predominant virus responsible for the flu outbreak is due to its ability to undergo constant mutations of the genetic material, known as antigenic drift.  It can change from one season to another and even during the same season.  This phenomenon is particularly true if the predominant strain is H3N2 and if the vaccine production is egg-based (less stable vaccine).  The vaccine effectiveness studies since 2009 have shown that when the vaccine and circulating virus are well matched the flu vaccine provides better protection against influenza B and influenza A H1N1 as compared to H3N2. Thus the severe and widespread nature of flu activity this year is likely a result of the predominant H3N2 strain which underwent drifting.

What is the estimated effectiveness of flu vaccine this year?  The vaccine effectiveness studies from 2005-2017 showed that if the vaccine and circulating H3N2 are not well matched the vaccine effectiveness is close to 23%.  Before this flu reached the Northern hemisphere, Australia had a bad flu season, in which the predominant strain was H3N2 and the vaccine effectiveness was only 10%.  It is still too early in the season to provide estimated vaccine effectiveness in United States.  The Centers of Disease Control and Prevention conducts observational studies at 5 outpatient sites across the country to measure the vaccine effectiveness.  The effectiveness implies ability of the flu vaccine to prevent infection.  It is calculated as the odds of vaccination among outpatients with influenza-like illness and laboratory confirmed influenza infection to the odds of vaccination in outpatients with influenza-like illness but are negative influenza test.

If the vaccine is not a good match to the predominant H3N2 circulating strain, should one continue to advocate for vaccination?  Yes, the match is not ideal for this year, but the antibody production from the vaccine strain will continue to provide some degree of protection against the circulating strain.  This protection might not prevent the occurrence of infection but the vaccine will reduce the probability of a further severe infection, hospitalization, and even death.

When should one prescribe antivirals?  The two classes of antivirals approved for treatment of influenza are neuraminidase inhibitors which includes oseltamivir (oral) and zanamivir (inhalation) and the adamantanes (amantadine and rimantadine; high resistance is seen).  Oseltamivir remains the treatment of choice.  It is approved for neonates as young as 2 weeks of age.  Oseltamivir’s resistance to the circulating viruses over the past few years is around 1%.  One of the limiting factors of its use in children is the associated nausea and vomiting.  The recommendations for treatment are limited to:

  1. Any child who is admitted to the hospital due to severe, complicated, or progressive respiratory disease irrespective of immunization status and duration of illness ≥48 hours.
  2. Outpatient therapy should be offered to any child at risk of complications such as children less than 2 years or underlying medical problems. Treatment should be offered to symptomatic siblings less than 6 months of age.  In addition it can be used for term and preterm infants after birth based on limited pharmacokinetics and safety data.  Best outcome is seen with early treatment started within the first 48 hours.
  3. Premavir is an intravenous formulation for treatment of influenza reserved for severe cases when oral oseltamivir cannot be used.

In this hard hit flu season, some of the other important recommendations regarding flu vaccinations are as below:

  1. The inactivated flu vaccine is recommended for children ≥6 months and older. Both trivalent and quadrivalent preparations are available.  The live nasal influenza vaccine is not recommended for this 2017-18 season due to lack of effectiveness.
  2. One should continue to offer influenza vaccination while flu activity is present in the community.
  3. The only contraindication to vaccination is a severe anaphylaxis to a prior influenza vaccination. A history of mild (hives) or severe hypersensitivity (anaphylaxis) to eggs is not a contraindication.  If there is a history of severe egg allergy then the vaccine should be administered by a healthcare worker who is able to recognize and treat anaphylaxis reactions.
  4. Prophylaxis with oseltamivir should be recommended to close contacts that are at higher risk of developing influenza complication. Prophylaxis is not recommended in infants less than 3 months of age unless the situation is judged as critical.
  5. A cell grown vaccine by the name of Flucelvax is available for children 4 years of age and above. It might provide better protection against H3N2 but the main benefit is flexibility in manufacturing.

In this particularly difficult flu season, one should continue to be an advocate for the flu vaccine to lessen the severity and extent of the outbreak.

(Dr. Leonard Krilov, MD, FAAP is Chairman of Pediatrics and Chief of the Division of Pediatric Infectious Disease at NYU Winthrop Hospital.  He is the Co-chair of the Infectious Disease Committee of the NYS AAP Chapter 2.  Dr. Asif Noor, MD, FAAP is Pediatric Infectious Disease Attending at NYU Winthrop Hospital and member of NYS AAP Chapter 2)

September 2017

Dear NYS AAP – Chapter 2 Member,

The newly elected officers of the New York State American Academy of Pediatrics (NYS AAP) – Chapter 2 would like to introduce themselves, solicit your input, and involve you in promoting child (and pediatrician) health in our region.

We will serve in these offices until July of 2019 and hope to accomplish much during that time.  Even more important is the fact that chapter membership offers multiple opportunities to network, learn new skills, contribute opinions, suggest new initiatives, educate, and advocate.

As local pediatricians in a chapter almost 70-years old, your local AAP’s credibility, combined with the expertise of its members, is in a unique position to improve the care of children in our region.  With your help, we can have even more influence in shaping the policy and future of health care in New York State.

While most of the AAP’s 10 Districts are made up of multiple states, New York and California each comprise a District.  There are three Chapters within the NYS AAP (District II), and our Chapter 2 has approximately 1,400 members from the boroughs of Brooklyn and Queens, and the counties of Nassau and Suffolk.  Chapter 3 is composed of Manhattan, the Bronx, Staten Island, and the upstate counties of Dutchess, Orange, Putnam, Rockland, and Westchester.  Chapter 1 covers the rest of New York State.

Because AAP members from New York City are split between Chapters 2 and 3, look for increased collaboration between the Chapters through our Committees and initiatives that further our agenda in New York City and the surrounding metropolitan area.

Now a little about us:

NYS AAP – CHAPTER 2 OFFICERS & STAFF

Steven J. Goldstein, MD, FAAP

Steven J. Goldstein, MD, FAAP

President
Steven J. Goldstein, MD, FAAP
sjg34@cornell.edu
Follow Chapter 2 on Twitter @NYSAAPCH2
Follow me on Twitter @SteveGoldstei10I am a general pediatrician with offices in Brooklyn and Queens.  In my
work as Chair of the Pediatric Council I advocate for children’s
healthcare coverage and for fair payment for pediatric services.  I
believe that a healthy future for our nation and a competitive workforce
in the global marketplace depends on raising our children in safe
environments with adequate nutrition, educational opportunities, and
quality pediatric healthcare.

Shetal Shah, MD, FAAP

Shetal Shah, MD, FAAP

Vice President
Shetal Shah, MD, FAAP
shetaldoc@hotmail.comI am a practicing neonatologist and Professor of Neonatology and
Pediatrics at Maria Fareri Children’s Hospital/New York Medical
College.  My interests include neonatal immunology (particularly
immunizations), stem cell therapy and neonatal healthcare policy.  My
work with the AAP started when I wanted to help pass a law in NYS to
promote influenza immunization.  My work with the local AAP Chapter
showed me the power of dedicated individuals to institute change.  We have had much success, but there is still work to do!

Robert Lee, DO, FAAP

Robert Lee, DO, FAAP

Secretary
Robert Lee, DO, FAAP
robertlee.do@gmail.comI am an academic pediatrician and Associate Residency Program
Director at NYU-Winthrop Hospital.  As Co-Chair of the new Foster
and Kinship Care Committee, I advocate for children exposed to toxic
stress.  I will help develop quality educational programs and work to
engage the members with the goal of improving children’s health
through policy, advocacy, and education.

Sara Kopple, MD, FAAP

Sara Kopple, MD, FAAP

Treasurer
Sara E. Kopple, MD, FAAP
SaraKopple@gmail.comI am a general pediatrician and Assistant Professor of Clinical
Medicine at The New York-Presbyterian/Queens Medical Center.  My
interests include early childhood development, legislative advocacy,
and medical education.  I believe our role as pediatricians in the
community is to advocate and provide a voice for children and
families on an individual and population level.

Jessical Geslani

Jessica Geslani

Executive Director
Jessica Geslani
jgeslani@aap.orgOn July 1, 2017, Jessica Geslani assumed her new position as
Executive Director of the Chapter.  She will also serve Chapter 3,
facilitating our joint initiatives.We welcome Jessica to her new responsibilities.

Elie Ward

Elie Ward

Director of Policy, Advocacy & External Relations
Elie Ward, MSW
eward@aap.netElie Ward also transitioned into a new position in July, and we
welcome her efforts to represent the members of the District both in
Albany and New York City.  She will also assist in Grant
Management for the Chapters.

GET INVOLVED IN THE NYS AAP – CHAPTER 2!

Do you have a particular interest, specialty or passion within Pediatrics?  Do you perceive the need for an educational program we have not addressed?  Our Committees welcome new members and new ideas.  The Committees, their Chairs, and contact information are listed here: http://ny2aap.org/chapter-committees/.

Send an introductory email to us or to a Committee Chair and join with us and pursue your interest or passion!

We will be publicizing a number of events of interest to our members in the coming weeks, and hope you will join in.  The AAP’s National Conference and Exhibition was in Chicago this year, from September 15 to 19, and fulfilled its promise to be a great way to network, learn, and develop our skills.  The NCE is in Orlando next year, and the NCE site can be reached here: http://aapexperience.org.

We are on social media.  Please sign up for Chapter 2’s Twitter account @NYSAAPCH2 to get a daily, 140-character dose of the work we do each day to make our region a healthier place for children and a more practice-friendly environment.  If you need help creating a Twitter account, contact Jessica Geslani at jgeslani@aap.org.

The Officers of the Chapter look forward to working with you in the coming years.  Please let us know what you need and how we can engage you in our vital work.

Sincerely,
Steve Goldstein
Shetal Shah
Robert Lee
Sara Kopple


 

Bright Futures

Robert Lee, DO, FAAP

Robert Lee, DO, FAAP

 

(Dr. Robert Lee, DO, MS, FAAP is a pediatrician and Associate Pediatric Residency Program Director at NYU Winthrop Hospital.  He is NYS AAP Chapter 2 Secretary and Co-Chair of the Foster/Kinship Care Committee.  He is a member of the Middle Childhood Expert Panel for the Bright Futures Guidelines, 4th Edition.)

 

What is Bright Futures?

Bright Futures

Bright Futures

Bright Futures is a set of principles, strategies, and tools that are theory based, evidence driven, and systems oriented that can be used to improve the health and well-being of all children through culturally appropriate interventions that address their current and emerging health promotion needs at the family, clinical practice, community, health system, and policy levels.

Bright Futures is a national health promotion and prevention initiative, led by the AAP and supported by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau.  The book, Bright Futures Guidelines, 4th Edition, is the core of the Bright Futures tools for practice and provides theory-based and evidence-driven guidance for all preventive care screenings and health supervsion visits.  The Bright Futures Tool and Resource Kit that accompanies the book is designed to assist pediatricians in planning and carrying out health supervision visits.  It contains numerous charts, forms, screening instruments, and other tools that increase practice efficiency and efficacy.  According to Joseph Hagan, MD, FAAP (Bright Futures Co-Editor), “The Periodicity Schedule tells us what should be done in a well visit, I believe Bright Futures tells us how to do it well.”

What’s New in the Fourth Edition?

The Fourth Edition builds upon previous editions with thoroughly revised and updated content that reflects the latest research.  Because of the science of early brain development,  adverse childhood events (ACEs) and toxic stress, environmental and social determinants of health, the AAP has adopted an eco-bio-developmental model of human health and diseases (Figure).  Bright Futures incorporates this new science into the development of a new health promotion theme: Promoting Lifelong Health for Families and Communities.  It provides a current review of the science of development and insight for how this science might be applied in our practices and clinics.  For most visits, pediatricians are encouraged to ask about topics such as food insecurity, domestic violence, substance use, housing situations and other issues that may affect a family’s health.  In addition, there are major updates to several adolescent screenings including: cervical dysplasia; depression; dyslipidemia; hearing; vision; tobacco, alcohol, and drug use.

How is New York State using Bright Futures?

The New York State Department of Health (DOH) is leading the implementation of Bright Futures.  DOH has worked with many state partners to ensure that Bright Futures Guideline is the primary resource for preventive services and health care supervision.  DOH began by working with NYS Medicaid office to infuse Bright Futures into the Medicaid provider handbook.  Specifically, the handbook includes the Periodicity Schedule, which DOH updates to match any changes made by the AAP.  Next, DOH shared the Bright Futures Guidelines with other state agencies, demonstrating their relevance to the agencies’ work and generally increasing awareness of Bright Futures.  DOH also shared the Bright Futures Guidelines with the Office of Mental Health for use with children and youth with emotional health issues.  The use of Bright Futures across these agencies allows state programs to communicate using a common language.

The NYS AAP Chapter 2 and 3 Pediatric Council have worked with individual insurance providers to explain the importance of Bright Futures recommended services, such as developmental screening, in sustaining child health and to ensure providers receive insurance payments for services recommended by Bright Futures.

 How can Pediatricians implement Bright Futures into their Practices?

Many pediatricians have asked whether it is really possible to implement the recommendations in Bright Futures Guidelines in daily clinical practice.  The answer is Yes!  Carrying out Bright Futures means making full use of all the Bright Futures materials. For pediatricians who wish to improve their skills, Bright Futures has developed a range of resources and materials that complement the Bright Future Guidelines.  The Bright Futures Tool and Resource Kit allows pediatricians who wish to improve their practice or services to efficiently and comprehensively carry out new practices and practice change strategies.  The Bright Futures tools also are compatible with suggested templates for the electronic health record (EHR).

  • Bright Futures Previsit Questionnaire, which a parent or patient completes before the pediatrician begins the visit. When the questionnaire is completed, the family’s agenda, and many of the child’s strengths, screening requirements, and intervention needs, is highlighted.
  • Screening tools, such as standardized developmental assessment tests and screening questionnaires that allow pediatricians to screen children and youth for certain conditions at specific visits.
  • Bright Futures Visit Chart Documentation Form, which corresponds to the Bright Futures Guidelines tasks for that visit and the information that is gleaned from the parent questionnaire. It reduces repetitive charting and frees the pediatrician for more face-to-face time with the child or youth.
  • Bright Futures Preventive Services Prompting Sheet, which affords an at-a-glance compilation of work that is done over multiple visits to ensure completeness and increase efficiency.
  • Parent/Child Anticipatory Guidance Materials, which reinforce and supplement the information discussed at the visit.

For more information about how to implement Bright Futures recommendations click here.