March 2019

March 9, 2019 by AAP2Master

Steven J. Goldstein, MD, FAAP

Dear NYS AAP – Chapter 2 Member,

As a Chapter, and in cooperation with Chapters 1 and 3 as the NYS AAP (District II), we have been involved in governmental affairs and initiatives in New York City, Long Island, Albany, and in Washington that will benefit the children we serve and society as a whole. We are proud to share these efforts, and other important information with you. Please see below for details.

Steven J. Goldstein, MD, FAAP
President, NYS AAP – Chapter 2
SJG34@Cornell.edu

DON’T MISS THE NYS AAP’S ANNUAL ADVOCACY DAY!

WHEN:	Tuesday, March 19, 20198:00am Breakfast 9:00am Morning Session Begins 12:00pm Lunch, followed by Scheduled Visits with Legislators 3:30pm Adjourn
WHERE:	University Club 151 Washington Ave. Albany, NY 12210
WHO:	This event is for members of the NYS AAP – Chapters 1, 2 & 3. There is no charge to attend.
WHY:	Come to the State Capitol and Advocate for Kids and Pediatricians! Meet Key Legislators and State Agency Decision Makers. Meet with Your Assemblymember & Your Senator to educate them about the important issues in children’s health and well being.

Advocacy for Gun Violence Prevention

On February 25th in New York City, Governor Andrew Cuomo, with House Speaker Nancy Pelosi at his side, signed landmark legislation known as the “Red Flag Bill” creating a mechanism for ERPO, Extreme Risk Protection Orders in New York State. This bill allows teachers and administrators to request that guns belonging to individuals seen as unstable or as a threat be confiscated pending a hearing in order to protect students and society. The Chapter has been advocating for ERPO legislation for years. Members of Chapters 2 and 3 were in attendance at this historic signing.

On March 4th we received word that the NY State Senate and Assembly passed Gun Safe Storage legislation. Elie Ward, our Director of Policy, Advocacy & External Relations, played a role in crafting this landmark achievement, which was bolstered by the unceasing advocacy efforts of Chapter members.

But there is more to be done! Our advocacy on Funding for Research about gun violence prevention at the state and federal levels is ongoing. We need your voice!

Chapters 2 and 3 recently joined with Chapter 1 to create a statewide committee to address gun violence prevention in New York. If you would like to get involved, please email our Executive Directors: Chapters 2 & 3, Jessica Geslani at jgeslani@aap.org, and Chapter 1, Chris Bell at cbell@mcms.org.

Chapter 2 Legislative Committee Member Dr. Eve Krief is in the white coat and to the right of Governor Cuomo

Chapter 3 Member and Co-Chair of the joint Chapters Gun Violence Prevention Committee, Dr. Nina Agrawal, is in the white coat to the left of the Governor, pictured with members of New Yorkers Against Gun Violence.

National AAP President Dr. Kyle Yasuda (left) and Chapter 2 VP Dr. Shetal Shah (right) flanking Senator Charles Schumer’s Legislative Aides at appointment in February advocating for gun violence prevention legislation.

Vaccine Exemptions

Sometimes the work that you don’t see is important. Vice President Shetal Shah and Legislative Committee Member Eve Krief visited NY State Senator Monica Martinez to discuss her bill to streamline applications for vaccine exemptions. Subsequently, she agreed to rewrite the bill and have us review it. The Chapters and National AAP believe that the only vaccine exemption should be for legitimate medical reasons.

Drs. Shah and Krief with aides of State Senator Martinez

Updates on Immigration Issues

Decision Reversed to Move an ICE Facility to the Nassau University Medical Center – Nassau County Executive Laura Curran reversed her decision to move an ICE facility to the Nassau University Medical Center, a move that could inhibit families from seeking healthcare for their children. The Chapter sent a strongly worded protest within 24 hours of her initial decision, contributing to her reversal.
Congressman Jerry Nadler Opens Hearings on Family Separation – “In our first immigration-related hearing this Congress, the Judiciary Committee will finally hold this Administration accountable for its indefensible and repugnant family separation policy, and for the injuries it has inflicted on thousands of children and families.”
Congressman Nadler’s remarks linked here are worth reading. He refers to the AAP’s work on family separation.
Kids on the Line – An ongoing investigation into family separation and the treatment of migrant children.

Chapter 2 Membership Committee – Call for Members!

Juan C. Kupferman, MD

As Membership Committee Chair, I would like to invite you to join the Committee to brainstorm about new ideas to increase our membership and improve the experience of our current members. Plans for a first dinner meeting at a restaurant are underway.

I am a strong believer in teamwork and look forward to collaborating with you and hearing your ideas! Please join me!

My best regards,
Juan C. Kupferman
JKupferman@maimonidesmed.org

RECORDED WEBINAR – “Don’t Be Lost in Transition:
Prepare & Efficiently Transfer Youth With and Without Special Health Care Needs to Adult Medical Care”

Many pediatricians feel unprepared to help their patients transition to adult medical care. Click this link to watch an excellent introduction to the issue with valuable resources from Drs. Sophia Jan of Chapter 2 and Lynn Davidson of Chapter 3. The webinar took place on February 28th and is worthy of your attention.

Annual Leadership Forum

The AAP Annual Leadership Forum, where resolutions and policy suggestions from AAP members are discussed and voted on, takes place in mid-March at AAP headquarters in Itasca, Illinois. Chapter 2 has a number of resolutions that will be considered and has been nominated for the Outstanding Chapter Award in the Large Chapter category. We’ll keep you posted as the ALF progresses.

Here is a link to the entire roster of ALF Resolutions.
Chapter 2 initiated resolutions may be found here and are listed below:

“Public Education About Intramuscular Vitamin K Administration at Birth” by Shetal Shah
“Revising the AAP Bright Futures Guidelines on Gun Safety Anticipatory Guidance” by Jennifer Grad, Dani Holmes and Christian Pulcini
“Expansion of Options for Publications as Membership Benefits” by Jack Levine
“Chapter Membership for Executive Committee Members of AAP National Sections, Councils, and Committees” by Steve Goldstein

New NYS School Health Examination Form Implementation Update

New NYS School Health Examination Form Implementation Year Memo – The memo linked here communicated that the NYSED is working with medical providers through their professional organizations (such as the NYS AAP) to develop a format that can be utilized in electronic health record systems. Until further notice you should continue to accept any health exam form received. The NYSED will disseminate information in the coming months regarding changes to the form along with when it will be required. Stay tuned for updates!

CDC Request for Measles Outbreak Support

From January 1 to February 21, 2019, 159* people from 10 states (CA, CO, CT, GA, IL, NJ, NY, OR, TX, and WA) have been reported as having measles. Five outbreaks (defined as 3 or more linked cases) have been reported, in Rockland County, New York; Monroe County, New York; New York City; Washington; Texas; and Illinois. Of these outbreaks, 2 outbreaks are ongoing from 2018. CDC urges healthcare professionals to ensure that all patients are up to date on MMR vaccine, including before international travel.

What Should Clinicians Do?

Discuss the importance of MMR vaccine with parents. Listen and respond to parents’ questions. When parents have questions, it does not necessarily mean they won’t accept vaccines. Sometimes, they simply want your answers to their questions.
Ensure all patients are up to date on measles, mumps, rubella (MMR) vaccine: 1) – Children need 2 doses of MMR: one dose at 12-15 months and another dose at 4-6 years. 2). Before any international travel, infants 6-11 months need 1 dose of MMR vaccine, children 12 months and older need 2 doses separated by at least 28 days, and teenagers and adults who do not have evidence of immunity against measles need 2 doses separated by at least 28 days.
Consider measles in patients presenting with febrile rash illness and clinically compatible measles symptoms (cough, coryza, and conjunctivitis), and ask patients about recent travel internationally or to domestic venues frequented by international travelers, as well as a history of measles exposures in their communities.
Promptly isolate patients with suspected measles to avoid disease transmission and immediately report the suspect measles case to the health department.
Obtain specimens for testing from patients with suspected measles, including viral specimens for genotyping, which can help determine the source of the virus. Contact the local health department with questions about submitting specimens for testing.

For more information, including guidelines for patient evaluation, diagnosis and management, visit: https://www.cdc.gov/measles/hcp/index.html

We’ll help you pursue your passion within Pediatrics! Send us an email describing your interest and we will connect you with the right people to get you involved. Please contact me or our Executive Director, Jessica Geslani, at jgeslani@aap.org

Follow Chapter 2 on Twitter: @NYSAAPCh2

My best,
Steve Goldstein, Chapter President SJG34@Cornell.edu | Twitter: @SteveGoldstei10

and the Officers:
Shetal Shah, Vice President shetaldoc@hotmail.com | Twitter @NICUBatman
Robert Lee, Secretary rlee@aap.net
Sanjivan Patel, Treasurer sapatel@wyckoffhospital.org

Measles Crises as Vaccine Refusals Rises

March 6, 2019 by AAP2Master

Asif Noor, MD, FAAP

Dr. Asif Noor, MD, FAAP is a Pediatric Infectious Disease Specialist at NYU Winthrop Hospital and he co-chairs the Infectious Disease Committee of the NYS AAP Chapter 2)

It’s 5:00 p.m. on a Friday evening and I was about to finish seeing the last patient at our ID clinic. My colleague informs me that she got paged for a consult regarding an infant with fever and a rash. The concern is measles. It is an infection which was declared eliminated from the United States about 18 years ago. Several communities in New York are now grappling with it. We struck up a conversation about our experience with measles. As millennial pediatricians, we were able to recall plenty of false alarms but not many true measles cases. My iPhone buzzes! There is a message on “Physician Dad’s Group” on Facebook. One of the physicians witnessed a cancer patient, who survived cancer, now succumbed to measles. This brought in mixed feelings of frustration and devotion to immunization.

Measles is highly contagious. It is a serious infection and can lead to death among the vulnerable population: young children and the immunocompromised. On the contrary, the measles vaccine is highly effective. The first MMR vaccine, developed by Maurice Hillman and colleagues, was widely distributed beginning in 1968. By 1981 measles cases reduced by 80%. An outbreak of measles in the vaccinated group children in 1989 led to the recommendation of a second dose of MMR in all children which further reduced measles cases. The Americas were declared measles free in 2000 after a 12 month period with 0 reported cases. This was all made possible by pairing of a safe and effective vaccine with an efficient vaccination program.

Measles has reappeared. Since 2000, the annual number of cases ranged from 37 in 2004 to 667 in 2014. A few months into 2019 and we already have 127 confirmed cases nationwide. This time it’s not an outbreak in a Disneyland theme park, rather the affected children are from our neighborhoods in New York. Since October 2018 there have been 90 cases of measles in Brooklyn, 138 cases in Rockland County, and 64 cases in Clark County, Washington State. There is a strong possibility that the millennial pediatricians might encounter measles which was once declared eliminated before they even entered medical school.

The two plausible elements responsible for measles flare up are 1) unvaccinated infected foreign travelers and 2) unvaccinated people. Let’s see how both of these factors are contributing to the recent surge in measles cases:

Firstly, air travel has shrank the globe into a village. Measles outbreak in one part of the world can reach our neighborhood in less than 24 hours. In 2014, a large outbreak in Orange County, California was imported from a case of measles in the Philippines where there was an ongoing epidemic. The current, 2018-19 explosion of measles in the United States started with travelers returning from local outbreak regions in Israel and the Ukraine. Limiting travel of someone with measles is an unrealistic control strategy because the disease can be contagious 4 days before and 4 days after rash onset. Screening for prodromal viral symptoms and rash on this large scale is not possible by non-medical personnel at the air ports. Spread is inevitable! Sporadic measles cases from travelers will continue until measles is eradicated worldwide.

Secondly, unvaccinated pockets of people are highly susceptible to this contagious virus. Sure enough the ground zero in the ongoing measles outbreaks are communities with unimmunized children. There has been a gradual rise in unvaccinated children over the past 18 years. For example in Clark County only 76.5% of kindergarteners were vaccinated against measles, whereas 95% need to be vaccinated for herd immunity. This vacuum created by the unvaccinated provides the perfect recipe for spread of measles.

The tyranny of anti-vaccination is primarily parental refusal. As a pediatrician we need to understand the most common reasons to allow informative conversation in a timely fashion:

Religious: Majority of the parents base their choice of not vaccinating their children on religious backgrounds. No mainstream religion is against vaccination. Vaccines indeed serve to protect human life and respect the principles of not harming self or public.

Link to Autism: Some parents are concerned about autism and MMR. This claim was propagated in the flawed The Lancet article by Andrew Wakefield, which became the most infamous retractions in history of science. Multiple follow-up studies did not find any such association.

Vaccine safety: Few parents express great concern of vaccine safety due to vaccine components, i.e. thimerosal. These components were removed from the vaccines more than a decade ago and current vaccine are safer to administer. Some parents fear that overwhelming their child’s immune system with too many vaccinations at one time has negative outcomes. Again, this belief does not have any scientific evidence.

Personal beliefs: Some parents make it a matter of freedom of choice based on philosophical reasons. Such freedom should never harm the most susceptible and defenseless amongst us.

Parents who refuse vaccines should be advised that New York State law prohibits unimmunized children from attending school during outbreaks. Parents should be encouraged to read the applicable law(s). Information on religious, philosophical, and nonmedical exemptions for immunization are available online (http://vaccinesafety.edu/cc-exem.htm).

As a pediatrician we have dual responsibility of medical care and vaccine advocacy during this ongoing measles outbreak. In addition to the infected child at risk, there is also a societal cost for investigating the potentially large number of those exposed to the index case.

Medical care: We need to be vigilant and consider measles in a child presenting with fevers and rash if they are unvaccinated. A careful history of exposure to a case of measles and recent foreign travel from an endemic region should be obtained. Any suspected case should be placed under airborne precautions in a negative pressure room (hospitalized). Measles infection can be confirmed by using RNA PCR by at least nasopharyngeal swab and serum. New York State laboratory at Wadsworth can perform the PCR assays. A positive IgM can also be used to confirm the cases however it has low positive predictive value. IgG can be used for case confirmation with a 4 fold rise in acute and convalescent titers. There is no antivirals, however vitamin A should be given to all children admitted with measles to the hospital.

Vaccination: We should continue to be a passionate advocate for MMR vaccination. During this outbreak setting, if there is an exposed case, administer MMR vaccine if unvaccinated, or if history of single dose, provided ≥ 28 days have elapsed after the first dose. Infants’ ≥ 6 months of age should be given MMR if they are living in the currently affected communities in Rockland County, Brooklyn or Clark County. This however will not be counted towards the 2 dose MMR series.

Our infant luckily just had roseola. It did serve as a reminder to stay on guard for a measles case in the current outbreak situation and be a voice for vaccines in contempt of parental refusals.

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