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2019 Legislative Session Update: WHAT WE ACCOMPLISHED!

Elie Ward

Elie Ward

Mrs. Elie Ward, MSW is the Director of Policy, Advocacy, and External Relations for NYS AAP Chapters 1, 2 &3.  She provides an update on the status of issues for which pediatricians across the state strongly advocated.

As you may have read or heard, this year’s legislative session has been extremely productive. I am very pleased to report that it has also been very productive and positive for the children of New York.  Many of our key legislative priorities, like the repeal of Religious Exemption to Immunization, Lowering Blood Action Level from 10 mg/dl to 5 mg/dl, and passage of a Gun Safe Storage Act, were achieved.  In addition, we had several significant legislative successes in the areas of child safety, the environment, and further curbs of tobacco access for young people.

The following is a summary of our victories in the legislative arena.  Many of our bills which passed both houses still need to be signed by the Governor.  Most have been agreed to and the Executive has indicated that they will be signed.  If we encounter resistance or an assault by opponents, such as the chemical industry fighting the Child Safe Products Act, I will let you know, and we will activate our Advocacy Action Alert system.

But for now, enjoy the fruits of your labor. We couldn’t have done this without the active participation of you, our members, as well as the close support and coordination from our partners in medicine, public health, early childhood development, child safety, child well-being, and environmental health.  Our friends and supporters in the legislature and in the Executive were also helpful.

Together we raised a strong and multi-focused voice for the children of New York. Here is what we accomplished:

  • 2371a/S.2994a: Medical Exemption Only for Immunization – Passed both Houses and signed by Governor all in one day!
  • 2686/S.2450: Gun Safe Storage – Passed both Houses
  • 0558/S.02833: Tobacco 21 (No one under 21 can purchase tobacco products) – Passed both Houses
  • 00217a/S.3788a: Crib Bumpers (Crib bumpers cannot be sold in NYS) – Passed both Houses
  • 7371/S.5341: Kids Safe Products (Banning & disclosure of dangerous chemicals in children’s products) – Passed both Houses
  • 576/S.1046: Conversion Therapy (No longer legal in NYS) – Passed both Houses and signed by Governor
  • 2477/S.5343: Chlorpyrifos Ban – Passed both Houses
  • 164/S.2387: Period Products Disclosure – Passed both Houses
  • 6295/S.4389: 1,4 Dioxane Ban – Passed both Houses

I will keep you informed as these bills move forward. In addition, there are several other bills directly related to children’s health and well-being that we will be watching that may move toward the Governor’s Office.

Now it’s time to refocus our work for next session and onto some of the serious child and family immigration issues that are currently impacting the health and well-being of thousands of children in our country and our state.


The Southern Border and the Power of Pediatricians

Steven J. Goldstein, MD, FAAP

Steven J. Goldstein, MD, FAAP

(Dr. Steven J. Goldstein, MD, FAAP is a pediatrician in Brooklyn and Queens. He is immediate past president of the NYS AAP Chapter 2 and serves as co-chair of its Pediatric Council and Committee on Environmental Health.

The list of priorities of the current administration that have the potential to harm the children we care for and future generations is startling.  Undoing climate change protections, reversing water and air pollution caps, opening pristine lands to mining, protecting pesticide use and manufacturers, shrinking National Parks, restricting health care initiatives designed to protect children, and even back-pedaling on what constitutes a healthy school lunch are just a few of these initiatives.  Pediatricians need to be familiar with these issues so that they can raise their voices in protest and do so in an authoritative way that will influence public opinion, and ideally change the conversation.  Pediatricians can help parents and grandparents understand these important issues that will affect their children and grandchildren.  Do not underestimate the power of 67,000 pediatricians to influence public policy.

The mistreatment of children and families at the US Southern Border is ongoing and pediatricians, parents, and citizens are becoming inured to the constant news drone about the wall and the immigration issue.  The demonization of those seeking asylum at the border with subsequent pushback from the public resulted in what was supposed to be a change in policy regarding the separation of children and families.  But that has not happened at all.  Indeed, recent news reports have shed light on new issues, many kept hidden by those in charge at the border, that are putting children at risk of illness, toxic stress, and death.

As the number of those seeking asylum has risen, the ability of the government to accept and care for new applicants has been overwhelmed.  Children have been kept in facilities meant for very short stays for much longer periods of time without adequate clothing, food, or access to healthcare. Some of these facilities, meant for housing single men, can’t meet the needs of children. Many children are still sleeping in cold caged-in spaces that are never darkened, with little or no access to healthcare.  And if that wasn’t bad enough, funding for schooling and other activities for these children has been cut.  Mothers entering the US and delivering babies have been separated in the postpartum period, with nursing babies sent to other states for foster care while the mother awaits an immigration court appearance.  These babies and mothers are not criminals.

The new “Remain in Mexico” policy, with refugees forced to apply for asylum in the countries along their route before entering the US, subjects children to further food insecurity, violence, and poor living conditions as the burden of caring for them falls upon unprepared governments.

While we have been dealing with measles nationwide, mumps is now epidemic in some detention facilities with 236 cases reported as of March 2019.  One trope of the administration is that immigrants spread disease but this is untrue. Central Americans often have better immunization histories than at least some American communities.  Pediatricians know that mumps vaccine is the least effective of our vaccine arsenal, as we have seen multiple institutional epidemics in previously immunized populations.  This epidemic may be related to the close, unsanitary quarters where these children are   housed.

As this story unfolds and children and families at the border continue to suffer under intolerable conditions, many of us wonder if somehow America has lost its moral bearings and forgotten that all human beings deserve compassion and respect no matter their origin or citizenship.

In the late 1800s, Emma Lazarus, moved by the plight of immigrants coming to seek refuge in our great land, composed the following poem that is on display now at the base of the Statue of Liberty. It is no less relevant today:

Not like the brazen giant of Greek fame,
With conquering limbs astride from land to land;
Here at our sea-washed, sunset gates shall stand
A mighty woman with a torch, whose flame
Is the imprisoned lightning, and her name
Mother of Exiles. From her beacon-hand
Glows world-wide welcome; her mild eyes command
The air-bridged harbor that twin cities frame.
“Keep, ancient lands, your storied pomp!” cries she
With silent lips. “Give me your tired, your poor,
Your huddled masses yearning to breathe free,
The wretched refuse of your teeming shore.
Send these, the homeless, tempest-tost to me,

I lift my lamp beside the golden door!”

Pediatricians have more power than most of us know.  Speak to your patients when the opportunities arise.  Change the conversation and promote kindness, acceptance, and tolerance for all who seek refuge in our great land.  This is not over.  We can influence the future of this country and the life trajectory of countless children.


Measles as The New “Normal”

Steven J. Goldstein, MD, FAAP

Steven J. Goldstein, MD, FAAP

Dr. Steven J. Goldstein, MD, FAAP is a pediatrician in Brooklyn and Queens. He is president of the NYS AAP Chapter and serves as co-chair of its Pediatric Council and Committee on Environmental Health.

With cases of measles appearing in 23 states and counting and well over 800 cases nationwide, Americans will have to adjust to life with possible exposure to measles as the new “normal”.   This is after measles was declared eliminated from the United States in the year 2000.

People of my generation dreaded getting the measles when we were children in the 1950s, but it was a rite of passage in that pre-vaccine era along with the other childhood diseases of mumps, rubella, and chickenpox.  The worst of those illnesses, however, was measles, which can lead to pneumonia and brain infections, and the residual effects of which include immune suppression which in turn leads to a greater likelihood of illness for two to three years after the illness.  And on top of that, children who have measles under the age of two years are at increased risk for subacute sclerosing panencephalitis (SSPE), a rare complication from the virus that is fatal and begins on average six to ten years after the acute illness.  One to two deaths per thousand cases occur in those afflicted by measles.

What is different today is the greatly increased number of immunosuppressed patients living in the community.  In the fifties, patients on chemotherapy in the community were rare and immunomodulator drugs used for a wide variety of chronic diseases but which suppress the immune system did not exist.  Babies have always been at risk, as the vaccine is not usually given until one year of age.  An extra dose of vaccine can be given starting at age 6 months for exposures or travel.

But what about travel by air, or train, or bus, even within the United States, with a young child, a cancer patient, or someone on immune-suppressing drugs?  Measles is extremely contagious and hard to diagnose in the four days before the rash appears, which leads to unintended exposure in schools, places of worship, airports, and even malls.  The virus persists in the environment for up to two hours after an infected individual leaves the area.  This is just another aspect of the measles issue and has the potential to change the way we live day-to-day.

Measles made its way to the Detroit area after a visitor from Brooklyn brought the unintended guest along for the visit.  And now, after a month or so without an active case, there is once again measles in the Detroit suburbs.  Mothers of young babies in affected communities are essentially being held hostage in their homes because they are afraid to expose their children to the illness.  My daughter will drive to New York to visit with her young baby rather than risk an exposure on the short flight from Detroit.

And that brings me to what we can do to deal with this problem.  Those of us in pediatric offices, hospitals, emergency departments, and urgent care clinics are dealing with this issue every day as we must decide whether a patient that needs to be seen could spread measles to others in our health care facilities.  The bottom line is that immunization with two doses of measles vaccine gives 97% of people immunity, whereas those who have opted out of vaccination due to fear, distrust, or for whatever reason, remain at risk of contracting and spreading disease.  Those with medical reasons not to get vaccine may be at higher risk of complications and need to be protected by others having immunity (this is known as herd or community immunity) so as not to allow the illness to spread.

No major religion-in fact, no religion at all known to me-prohibits immunization, and some actively promote preventative actions.  Currently, New York State grants exemptions for school entry solely for medical and religious reasons.  There is a bill in the NYS Assembly Health Committee (A02371/S2994) that would allow for only medical exemptions to immunization in the state.  The pediatricians of New York State strongly support that bill and do not feel that it impinges on anyone’s civil rights: the law would not require vaccination, only prevent unvaccinated children from putting the other children at risk.

The anti-vaccine movement sees their issue as one of personal freedom.  I see that, but society also has the right to protect itself.  I’m fine with people having the freedom not to vaccinate against their will, but not at all fine with unvaccinated children putting others at risk.  No one should have the right to spread disease to others and impede their freedom to attend school, camp, or day care, or to go shopping or to travel.

Call your NYS Assemblyman and demand that Assembly Bill 02371 to repeal religious exemptions be released from committee for open debate.


Believe The Science That Vaccinations Protect Children

Eve Meltzer-Krief MD, FAAP

Eve Meltzer-Krief MD, FAAP

Dr. Eve Meltzer-Krief MD, FAAP is a pediatrician in Huntington and member of the NYS AAP Chapter 2 Immigration and Legislative Advocacy Committees.  This op-ed was published ontimesunion.com on May 23, 2019.

 Vaccination has been the most important and impactful scientific achievement of modern times. Yet because of misinformation fueled by social media, there remain pockets of unvaccinated children whose parents hide behind a cloak of religious exemption as protection from unfounded fears.

There are, in fact, no major religions that prohibit vaccination.  Sadly, these parents have put not only their own children at risk but the communities in which their children live, play and attend school.  The current measles outbreak is evidence of what happens when children go unvaccinated.

Measles is a highly contagious virus.  The current outbreak has now infected at least 880 people in 24 states.  Measles can lead to pneumonia, a brain infection called encephalitis, deafness, a prolonged immunocompromised state, and a rare complication called subacute sclerosingpanencephalitis that can occur years after infection and is fatal.

In 1962, the year before the measles vaccine was available, 3 million to 4 million people were diagnosed with measles, 48,000 were admitted to hospitals and 500 died.  By the year 2000, measles had been eliminated from the United States because of the vaccine.

However, because of growing numbers of parents choosing not to vaccinate their children, we have begun to see increased outbreaks in recent years, with this year’s being the largest since the disease was eliminated nearly 20 years ago.  There are currently 285 schools that are underimmunized in New York that are vulnerable to outbreaks.  As the rate of individuals claiming religious exemptions continues to rise this number will only grow.  Particularly susceptible to serious illness in these outbreaks are infants who have not yet been vaccinated, and immunocompromised children and adults who are receiving or have recently received chemotherapy and other immunosuppressives to treat cancer and chronic diseases.

Vaccines save lives.  The HIB vaccine has virtually eliminated disease caused by HaemophilusInfluenzae B, which before the vaccine’s introduction in the 1980s and 1990s affected 25,000 children yearly, causing meningitis, paralysis, blindness, pneumonia and a severe life-threatening respiratory illness called epiglottis.  Since the introduction of the Prevnar vaccine in 2000 there has been a dramatic decline in rates of meningitis, blood infections and other invasive life threatening disease caused by pneumococcal bacteria.

Vaccines are scientifically proven to be safe and effective and have saved tens of millions of lives over the past several decades.  Parents today are lucky to live in a time when we do not have to live in fear of our children contracting serious and deadly diseases.  However, the current outbreak has demonstrated that if parents fall prey to misinformation and fail to properly vaccinate their children, they put their own children at risk as well as the most vulnerable among us.

The American Academy of Pediatrics, representing 67,000 pediatricians across the country, is advocating for an end to state laws that allow people to refuse vaccination based on anything other than medical exemptions.  I urge New York legislators to pass S2994 and A2371.  I implore them to believe science and to protect children and at-risk residents in our state.  I implore parents and community members who understand the importance of vaccination to ask their state legislators to support the bill.

It is always tragic when children die or develop devastating long-term consequences from disease.  The most tragic of those cases, though, are the ones that are entirely preventable. Let us not fail our children.  Let us not fail those among us who are immunocompromised, who are too young to get vaccinated or who are undergoing treatment that prevents them from getting vaccinated.  These individuals, parents and children live in fear during outbreaks such as we are experiencing now. Let us not deny them the protection they need and are entitled to.


School Vaccination Exemptions Should Be Only for Medical Conditions

Shetal Shah, MD, FAAP

Shetal Shah, MD, FAAP

Dr. Shetal Shah, MD, FAAP is a neonatologist at Maria Fareri Children’s Hospital.  He is NYS AAP Chapter 2 Vice President and Chair of the Legislative Committee.  This op-ed was published on northjersey.com on May 9, 2019.

Forty years ago, the United States eradicated endemic polio.  It was a cooperative, national effort to eliminate a major public health threat, made possible by a lifesaving vaccine, an army of healthcare professionals and by parents who chose to vaccinate their children — many waiting in line for hours.  Vaccines are considered one of the world’s greatest health achievements and are the main reason current parents of young children don’t remember polio, rubella, diphtheria and until recently, measles.  Prior to the creation of measles vaccine over a half-century ago, approximately 3-4 million US cases occurred annually, resulting in thousands of hospitalizations, cases of lifelong disability and hundreds of childhood deaths.

New York is again facing outbreaks of measles.  Almost 700 cases have been reported nationally the largest since the disease was considered domestically eradicated — largely from clusters of unvaccinated children in Brooklyn and Rockland County.  The number of infected keeps rising.  In a single week in April, 78 new cases were reported.

Washington State is also facing an outbreak and cases of measles span 22 states.  Since 2001, over 100 measles outbreaks have occurred, including the 2014 episode centered on Disneyland.

Pediatricians foresaw the return of vaccine-preventable diseases because each week, we spend hours discussing the importance of vaccination to increasingly skeptical parents who, fueled by misinformation as well as unsubstantiated claims nurtured on the internet, cite greater concerns about the vaccines than the diseases they prevent.

When vaccination rates decrease, the return of measles, (or pertussis, or mumps) is inevitable.  Parental refusal of vaccines is now so prevalent the World Health Organization declared it a “Top Threat to Global Health” this year, alongside HIV/AIDS and poor access to medical care.  While measles has captured the public’s attention, there have been 426 cases of mumps this year, approximately 300 in March alone.  Pertussis outbreaks occur so often they are now considered medically “routine.”

Worse than the suffering these diseases can cause (5 children have required intensive care from measles complications) is having the public health tools to prevent these illness and not using them.  This is why the New York State Legislature should pass bills A.02371/S.02994 and eliminate all non-medical exemptions to vaccination for school attendance.

New York State allows parents to obtain religious exemptions from vaccination and more parents are getting them. Though most major religions support immunization – rates of religious exemptions in the state are now high enough to weaken population immunity levels (herd immunity) that almost 300 schools in the state are at risk. Moreover, what is often overlooked is the general population vulnerability of these diseases in immune compromise individuals such as those suffering with cancer, and others with impaired immune defense mechanisms such as AIDS as well as those with true contraindications who cannot be immunized.

Though New York, unlike 17 other states, does not allow for a philosophical exemption (a wish to not be immunized simply because one is against vaccination), it is clear religious exemptions are often truly philosophical ones dressed in religious doctrine.  Having reviewed applications for religious vaccination exemptions, it’s clear many parents are trying to opt out of vaccination by co-opting religious texts – sometimes from multiple religions which parents state they do not follow.

Since religious exemptions are granted by local school boards, some parents feel if they complain enough, or threaten to sue, schools will relent.  This process also makes school boards de facto courts of faith, dissecting which exemptions are rooted in religious conviction and which are not – a job school officials do not want and are often unqualified for.

In the wake of this year’s measles cases, Washington State is attempting to learn from the outbreak.  A bill to restrict exemptions to vaccination passed the state’s Senate.  The question is, can New York learn the same lesson?

This measure, sponsored by Legislators Dinowitz and Hoylman enjoys widespread support from physicians, public health groups, healthcare workers and parents of school-age children.  If passed, the bill would put New York on equal footing with West Virginia and Mississippi – two states which have not experienced widespread outbreaks and with California – which despite having measles next door in Oregon has to date been spared a major repeat of its 2014 experience.

Regrettably, a small, well-organized group of opponents have harassed legislators and pediatricians, both in person and on social media. Their tactics not only are reprehensible and in some cases dangerous.  These groups have overtaken town halls and disrupted public events.  Protestors surrounded the car of New York State Senator Kevin Thomas, who supports the bill — and refused to leave, requiring the Senator to call the police.  Assemblyman Dinowitz has been told by anti-vaccine activists, according to a report, that they hope his “grandchildren get autism.”

Pediatricians support this bill because allowing only medical exemptions is a proven way to increase immunization rates and protect all children from vaccine-preventable diseases.  Since all kids who get immunized don’t generate an immune response sufficient to protect themselves, ALL parents should support this bill as a way to protect ALL our state’s children.  It eliminates school boards from becoming arbiters of vaccination exemptions – which leads to different standards in each district – and places authority to grant exemptions in the hands of physicians.

These epidemics should motivate legislators to understand the importance of strengthening our public health infrastructure.  If they fail to recognize the medical and epidemiological facts behind immunization and the policies which keep rates of vaccination high, then another outbreak is certain.


Legislators Need to End Most Vaccine Exemptions

Eve Meltzer-Krief MD, FAAP

Eve Meltzer-Krief MD, FAAP

(Dr. Eve Meltzer-Krief MD, FAAP is a pediatrician in Huntington and member of the NYS AAP Chapter 2 Immigration and Legislative Advocacy Committees.)

NYS Legislators: Please Support Bill that Will Allow Only  Medical Exemptions to Vaccination, S.02994 and A.02371

Vaccination has been the most important and impactful scientific achievement of modern times.  Yet because of misinformation fueled by social media, there remain pockets of unvaccinated children whose parents hide behind a cloak of religious exemption as protection from unfounded fears.  There are, in fact, no major religions that prohibit vaccination.  Sadly, these parents have put not only their own children at risk but the communities in which their children live, play and attend school.  The current measles outbreak is evidence of what happens when children go unvaccinated.

Measles is a highly contagious virus.  The current outbreak has now infected 695 people in 22 states.  Measles can lead to pneumonia, a brain infection called encephalitis, deafness, a prolonged immunocompromised state, and a rare complication called SSPE or subacute sclerosing panencephalitis that can occur years after infection and is fatal.  In 1962, the year before the measles vaccine was available, 3-4 million people were diagnosed with measles, 48,000 were admitted to hospitals and 500 people died.  By the year 2000, measles had been eliminated from the United States because of the vaccine.  However because of growing numbers of parents choosing not to vaccinate their children, we have begun to see increased outbreaks in recent years, with this year’s being the largest since the disease was eliminated nearly twenty years ago.

Particularly susceptible to serious illness in these outbreaks are infants under one year old who have not yet been vaccinated, and immunocompromised children and adults who are receiving or have recently received chemotherapy and other immunosuppressives to treat cancer and chronic diseases.

Vaccines save lives.  The Hib vaccine has virtually eliminated disease caused by Haemophilus Influenzae B which before its introduction in the late 1990’s affected 25,000 children yearly, causing meningitis, paralysis, blindness, pneumonia and a severe life-threatening respiratory illness called epiglottis.  Since the introduction of the Prevnar vaccine in 2000 there has been a dramatic decline in rates of meningitis, blood infections and other invasive life threatening disease caused by pneumococcal bacteria.

Vaccines are scientifically proven to be safe and effective and have saved tens of millions of lives over the past several decades.  Parents today are lucky to live in a time when we do not have to live in fear of our children contracting serious and deadly diseases.  However the current outbreak has demonstrated that if parents fall prey to misinformation and fail to properly vaccinate their children they put their own children at risk as well as the most vulnerable among us.

The American Academy of Pediatrics representing 67,000 pediatricians across the country is advocating for an end to state laws that allow people to refuse vaccination of their children on religious or philosophical grounds.  I urge NYS legislators in the Senate and Assembly to pass S.02994 and A.02371.  This bill will allow only medical exemptions to vaccination.  I implore our legislators to believe science and to protect children and at risk residents in our state.

I implore parents and community members who understand the importance of vaccination to ask their NYS legislators to support the bill.   It is always tragic when children die or develop devastating long term consequences from disease.  However the most tragic of those are cases that are entirely preventable.  Let us not fail our children.  Let us not fail those among us who are immunocompromised, who are too young to get vaccinated or who are undergoing treatment that prevents them from getting vaccinated.  These individuals, parents and children live in fear during outbreaks such as we are experiencing now.  Let us not deny them the protection they need and are entitled to.


The Return of Measles to a Neighborhood Near Yours

Steven J. Goldstein, MD, FAAP

Steven J. Goldstein, MD, FAAP

(Dr. Steven J. Goldstein, MD, FAAP is a pediatrician in Brooklyn and Queens. He is president of the NYS AAP Chapter and serves as co-chair of its Pediatric Council and Committee on Environmental Health. This blog post was originally published in AAP Voices on April 30, 2019)

The outbreak of measles in New York City brings back vivid memories more than half a century old.  I was 5 years old and was very ill, with a terrible cough, dry lips, crusted eyes, extensive rash, and high fever.  My pediatrician visited while I was sick, and he was a welcome sight.  I had terrible light sensitivity and spent most of the time in a semi-dark room.

Only in medical school did I learn that I had exhibited classic measles symptoms: cough, coryza, and conjunctivitis with photophobia, fever and rash.  The virus infected more than three-quarters of a million people and killed hundreds in the United States that year, a decade before the measles vaccine would become available.  Fortunately, I escaped serious complications of the disease.

I think the experience helped influence me to become a pediatrician.  Not a reason to contract measles, though.

As I age, I am less patient waiting for positive change as I realize the work of individual pediatricians to make the world a better place is time-limited.  This is one reason I am incensed by the return of measles to the neighborhoods where I practice.  As of April 29, there have been 423 confirmed cases of Measles in Brooklyn and Queens.  The vast majority of patients, roughly 84 percent, are infants, children and teens.

Vulnerable communities targeted with vaccine misinformation

My Brooklyn office serves a largely Chasidic clientele, with a melting pot of families from other backgrounds.  My Queens office patients are reflective of one of the most diverse communities in the US.  We first noticed a troubling trend in the Brooklyn office.  Starting in late 2017, there was a significant drop-off in babies and children coming in for well visits and immunizations.

An anti-vaccine group calling themselves PEACH (Parents Educating and Advocating for Children’s Health) in the ultra-Orthodox community of Lakewood, New Jersey sent out an illustrated, 40-page booklet filled with false information about vaccines.  Targeting isolated and fundamentalist communities, where the science of immunizations is not well known and accepted, is a known tactic of the anti-vaccine activists.

A helpful publication from the Hudson Valley Health Coalition that countered the misinformation with facts was distributed by the New York City Department of Health and supported by the CDC.  Our immunization rates dropped nevertheless, and it was the rare visit that did not engender a long discussion about vaccine risk, efficacy, and timing.  Long discredited claims of a possible MMR immunization and autism link were revived, and questions about the need for vaccines against “eliminated diseases” arose.

The ultra-Orthodox community in Brooklyn has seen measles before.  In 2013, an unimmunized child returned from London incubating measles, resulting in 58 cases in New York City.  Forty-five of the affected patients were eligible to receive vaccine but had not.

The toll of outbreaks on the health care system & practices

The costs to society of outbreaks such as these, which divert funds from worthy initiatives, are not trivial.  The costs to the Department of Health in the 2013 outbreak were calculated to be about $400,000.  According to federal estimates, the direct and indirect costs of each case of measles can run as high as $142,000.

As I write this, the ongoing spread of measles from Brooklyn causes worry about the possible spread to other municipalities, especially with recent holidays when many families traveled long distances.  The question of how to protect very young children remains, other than advising families not to travel and isolating them as much as possible.  But what about someone inadvertently bringing measles into our office, hospital, ED, or clinic?  This should be of major concern to all of us, because it has implications for structuring our schedules and patient encounters.

Facilities must close for two hours after measles is diagnosed because of the continued contagion of virus in the air.  Suspected cases also disrupt practices. Last week in Queens, we saw a 2 1/2 year old child with history of one MMR vaccine who attended a childcare nursery in Brooklyn, near to an affected community.  He’d had 4 or 5 days of fever and then developed a rash, so we had to consider measles.

We learned two days later from his lab work that the polymerase chain reaction was negative.  It was not measles.  Still, the burden on staff to check the immunization status of each child in the office those days and if needed, to contact their families, was huge.  Because of the time frame and age, some children would need immune globulin prophylaxis or vaccine, and might need to be quarantined for up to 28 days.  Newborns might have been exposed. I lost sleep.

The return of measles has the potential to profoundly influence the way we, in the affected communities, practice pediatrics.  We were extremely unhappy about the possibility that a child in our office might have exposed others.  Pediatricians will need to consider measles immunity, the possibility of measles in the pre-rash stage, and the incubation period when scheduling patients, and attempt to isolate susceptible patients from others if the epidemic spreads.

Wild measles: trampling families’ freedom from disease

Because of the spread of measles to the Detroit community, with 50 cases documented at last count, my own daughter has decided to forego daycare for her new baby and will hire a nanny to minimize the infant’s chance of getting the disease.

One argument the anti-vaccine community makes is that by insisting on immunization, we are infringing on individual freedoms.  What about the rest of the world that stands to suffer, with risk of death or disability, because of measles spread by vaccine refusers?  Wild measles is the gift that keeps on giving, with subacute sclerosingpanencephalitis (SSPE), a fatal, late onset measles complication, a real possibility.  Some of us think, given the number of cases so far, that there will be a major spike in SSPE in a few years.  Measles is not a benign disease.

This issue — the inability of young children and others susceptible to infectious diseases — is a cogent argument for the passage of bills eliminating all but medical exemptions for vaccines.  New York is considering this issue and other states should as well, joining California, West Virginia and Mississippi.  The most recent estimates suggesting that for every 1000 cases of measles, one or two patients die, it is clearly a public health issue.

In the meantime, as pediatricians fighting on the front line of outbreaks, we are faced with a new normal as we continue to factor measles into our decision-making when booking and seeing patients to protect our most vulnerable patients.  Most importantly, we continue our efforts to educate families about the dangers of measles–and how the decision not to vaccinate affects everyone around them.


Electronic Cigarettes Among Young People

Mary Cataletto, MD, MMM, FAAP

Mary Cataletto, MD, MMM, FAAP

(Dr. Mary Cataletto, MD, MMM, FAAP, FCCP is a pediatric pulmonologist and Associate Director of Pediatric Sleep Medicine at NYU Winthrop Hospital. She is chair of the Pediatric Chest Medicine NetWork of the American College of Chest Physicians and past chair of the Asthma Coalition of Long Island. She is Editor in Chief of Pediatric Allergy, Immunology and Pulmonology. She is the Nassau Pediatric Society Representative to NYS AAP Chapter 2.)

Published Online: March 8, 2019

Citation: US Respiratory & Pulmonary Diseases. 2019;4(1):Epub ahead of print

The Use of Sweetened and Flavored Electronic Cigarettes Among Young People—a Growing Concern

Electronic cigarettes (e-cigs) are often promoted as a safe alternative to conventional tobacco-based cigarettes and as an aid to smoking cessation.  The use of sweet and fruit-based flavorings, as well as targeted marketing strategies to attract teens, have resulted in a significant uptake in the use of these products in middle and high school students in the US.1 Potential customers can select from a vast array of flavoring options, and access information about e-cigs via social media and other online sources, as well as traditional marketing communication channels and face-to-face interaction with vape shop employees. The availability of sweetened and flavored brands has heightened their appeal for young people. However, despite substantial increases in e-cig consumption, little is known about the long-term health consequences of their use.

In an expert interview, Mary Cataletto discusses these issues, as well as a recent position statement of the Forum of International Respiratory Societies (FIRS) on the use of e-cigs in youths.

1. How prevalent is the use of electronic cigarettes in children and adolescents?

Based on the 2017 National Youth Survey published by the US Food and Drug Administration, 2.1 million American middle and high school students had used e-cigs in the past 30 days.1 E-cig use has surpassed the use of conventional tobacco cigarettes in this age group and they are the most commonly used tobacco product in middle and high school students.2

2. What role do flavorings play in adolescent electronic cigarette use?

The majority of youths, defined as between 12–17 years old, report that flavored e-cigs were their initiation into tobacco products, citing the availability of flavors and the ability to mix their favorite flavors as important factors.1–4 Adolescents who preferred more flavors used more e-cigs. Multimedia advertising promotes ‘natural’ flavors and aromas, so it is not surprising that flavors have also been reported as the main reason that teens continue to use them.5 There are thousands of flavors of e-cigs on the market (over 7,500 flavors estimated in 2014).6 The availability of multiple choices in flavors and the option to mix your own flavorings may help to maintain the novelty of e-cigs for teens and promote increased use. Fruit and sweet flavors are the most popular in youths. In a recent study by Kroemer at al., the addition of a sweet taste was shown to potentiate the reinforcing effects of nicotine.7

3. What has been the adult experience with flavored electronic cigarettes as an aid to smoking cessation?

Adult smokers are also influenced by flavorings, and the dual use of e-cigs and conventional tobacco is not uncommon.8 Many adults prefer menthol or tobacco flavor as they start to quit smoking, although sweet flavors become more popular as they continue to use e-cigs.3–4 It remains unclear whether e-cigs are an effective aid to smoking cessation.

4. Why is the use of sweetened electronic cigarettes among minors a controversial issue?

There is no safe amount of nicotine exposure, and e-cigs are not a safe alternative to conventional tobacco cigarettes.9 Many youths believe that e-cigs are safer and more socially acceptable.10 While more research is needed, it appears that the sensitization to nicotine in e-cigs promotes conventional tobacco use as the nicotine cravings increase. Few users recognize that they are a likely gateway to conventional tobacco cigarettes. The brain continues to develop throughout adolescence and is particularly vulnerable to the addictive effects of nicotine.9 The adverse effects of e-cigs include those ascribed to nicotine itself, the contents of the aerosol (vapor), or to the temperature modification of the content.11

The sale of both e-cigs and conventional tobacco products are banned to minors in the US, yet the 2017 US National Youth survey reported that approximately 2.1 million middle and high school students had used e-cigs in the past 30 days.1

5. What is being done to discourage the use of these products among minors?

FIRS issued a position statement on e-cigs and electronic nicotine delivery systems use in youth. FIRS reflects a collaboration of professional organizations and respiratory experts; it is made up of nine international societies: the American College of Chest Physicians, American Thoracic Society, Asian Pacific Society of Respirology, Asociación Latinoamericana de Tórax, the European Respiratory Society, the International Union Against Tuberculosis and Lung Disease, the Pan African Thoracic Society, the Global Initiative for Asthma and the Global Initiative for Chronic Obstructive Lung Disease.

They recommended:

  1. To protect youths, [electronic nicotine delivery systems] should be considered tobacco products and regulated as such, including taxation of electronic cigarettes and supplies. The addictive power of nicotine and its adverse effects in youths should not be underestimated.
  2. Considering the susceptibility of the developing brain to nicotine addiction, the sale of electronic cigarettes to adolescents and young adults must be prohibited by all nations, and those bans must be enforced.
  3. All forms of promotion must be regulated and advertising of electronic cigarettes in media that are accessible to youths should cease.
  4. Because flavorings increase rates of youth initiation, they should be banned in electronic nicotine delivery products.
  5. As electronic cigarette vapor exposes nonusers to nicotine and other harmful chemicals, use should be prohibited in indoor locations, public parks, and places where children and youths are present.
  6. While their health risks are increasingly recognized, more research is needed to understand the physiological and deleterious effects of electronic cigarettes.
  7. Routine surveillance and surveys concerning combustible and electronic cigarette use should be carried out in many settings to better understand the scope and health threat of tobacco products to youths in different countries and regions.’ [sic]12

In conclusion, it is clear that flavorings can influence initiation and contribute to the ongoing use of e-cigs. Nicotine is an addictive substance, and preteens and teens are particularly vulnerable. Legislation and enforcement of existing restrictions to targeted marketing to teens, sale to minors, as well as restriction of sweet and fruit flavorings, are important steps to protect the future health of our children. Additional studies are needed to further evaluate the safety and efficacy of e-cigs as an aid in smoking cessation.13

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  1. Wang TW, Gentzke A, Sharapova S, et al. Tobacco product use among middle and high school students – United States, 2011–2017. MMWR Morb Mortal Wkly Rep. 2018;67:629–33.
  2. US Food & Drug Administration. Youth tobacco use: National Youth Tobacco Survey. 2018. Available at: fda.gov/TobaccoProducts/PublicHealthEducation/ProtectingKidsfromTobacco/ucm405173.htm (accessed January 22, 2019).
  3. Huang LL, Baker HM, Meernik C, et al. Impact of non-menthol flavors in tobacco products on perceptions and use among youth, young adults and adults: a systematic review. Tob Control. 2017;26:709–19.
  4. Harrell MB, Weaver SR, Loukas A, et al. Flavored e-cigarette use: characterizing youth, young adult, and adult users. Prev Med Rep. 2017;5:33–40.
  5. Centers for Disease Control and Prevention. Quick facts on the risks of e-cigarettes for kisd, teens, and young adults. 2018. Available at: cdc.gov/tobacco/basic_information/ecigarettes/Quick-Facts-on-the-Risks-of-E-cigarettes-for-Kids-Teens-and-Young-Adults.html?s_cid=osh-stu-home-slider-004%20 (accessed January 22, 2019).
  6. Zhu SH, Sun JY, Bonnevie E, et al. Four hundred and sixty brands of e-cigarettes and counting: implications for product regulation. Tob Control. 2014;23 Suppl. 3:iii3–9.
  7. Kroemer NB, Veldhuizen MG, Delvy R, et al. Sweet taste potentiates the reinforcing effects of e-cigarettes. Eur Neuropsychopharmacol. 2018;28:1089–102.
  8. Kasza KA, Ambrose BK, Conway KP, et al. Tobacco-product use by adults and youths in the United States in 2013 and 2014. N Engl J Med. 2017;376:342–53.
  9. Schraufnagel DE. Electronic cigarettes: vulnerability of youth. Pediatr Allergy Immunol Pulmonol. 2015;28:2–6.
  10. Pepper JK, Ribisl KM, Brewer NT. Adolescents’ interest in trying flavored e-cigarettes. Tob Control. 2016;25:ii62–6
  11. Lodrup Carlsen KC, Skjerven HO, Carlsen KH. The toxicity of e-cigarettes and children’s respiratory health. Paediatr Respir Rev. 2018;28:63–7.
  12. Ferkol TW, Farber HJ, La Grutta S, et al. Electronic cigarette use in youths: a position statement of the Forum of International Respiratory Societies. Eur Respir J. 2018;51:pii:1800278.
  13. Farsalinos K. Electronic cigarettes: an aid in smoking cessation, or a new health hazard? Ther Adv Respir Dis. 2018;12:1753465817744960.

Measles Crises as Vaccine Refusals Rises

Asif Noor, MD, FAAP

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.


Witnessing History in Albany

Eve Meltzer-Krief MD, FAAP

Eve Meltzer-Krief MD, FAAP

(Dr. Eve Meltzer-Krief MD, FAAP is a pediatrician in Huntington and member of the NYS AAP Chapter 2 Immigration and Legislative Advocacy Committees.)

My alarm went off at 4:45am.  I got dressed and neatly folded my white coat into my bag, got into my car, and drove to the train station where I waited in the cold on the dark, deserted platform in Huntington, Long Island.  I was catching a train from NYC to Albany where dozens of other advocates were gathering from across the state, advocates including other physicians and moms and including individuals who had lost loved ones to gun violence.  We were all coming together to support the historic passage of gun safety legislation in New York State.

For some, like myself, it was our first time at the Capital watching Senate and Assembly proceedings.  For all of us, it represented the culmination of phone calls, letters, rallies and visits to legislative offices advocating for common sense gun legislation for our children.

As pediatricians, we know the impact that gun violence has on children in our country.  Nearly 1,300 children under 18 years old die from gunshot wounds every year and 5,790 are injured yearly.  Firearm related injury is the third leading cause of death among American youth.  A recent study showed that half as many children die from gun injuries in states with stricter gun laws compared to states with more lax gun laws.  Pediatricians know that gun violence is a healthcare epidemic for children in our country.

The pediatricians who were in Albany to witness the passage of the important gun safety bills stood up in applause along with Linda Beigel Schulman who lost her son to gun violence at Parkland and who burst into tears as one by one the gun safety measures were declared state law.  We watched as the Senate passed the Extreme Risk Protection Order bill and passed a law that will give up to 30 days to complete background checks.  They banned bump stocks and passed a bill preventing teachers from carrying guns.  They created regulations for gun buyback programs and passed a bill that allowed out of state mental health records to be reviewed before obtaining gun permits.  Common sense gun safety legislation.

Pediatricians also look forward to the passage of safe gun storage legislation that would require guns to be stored unloaded in a locked box separate from ammunition.  Studies show that 70% of childhood gun injuries, deaths and suicides would be prevented if the family weapon was locked up and unloaded.  Pediatricians from the NYS AAP also advocate for the establishment of a Gun Safety Research Institute in NY that would allocate funding for evidence based gun safety research and lead to recommendations for future gun safety measures.

It was inspiring and fulfilling to see our work lead to positive change .  I urge pediatricians to speak to their legislators about the issues they care about and to join your chapter’s legislative advocacy committee.  See you in Albany !