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Parents look online for atopic dermatitis advice
Many caregivers of children with atopic dermatitis do not receive clear instructions on how to properly use topical corticosteroids and seek advice on online forums, according to Emma Teasdale, PhD, and her associates.
The investigators analyzed 27 forum discussions involving 95 participants from 2003 to 2015 and found that parents expressed a range of beliefs regarding the use of topical corticosteroids. Some parents expressed positive views, but many were cautious and perceived topical corticosteroids as unnatural or too strong. Notably, parents said they believed that topical corticosteroids thinned or weakened the skin.
Parents also expressed uncertainty over how to use topical corticosteroids. Common questions involved duration of use, where and when to apply, and confusion over the strength of different preparations. Parents also noted that they received conflicting physician instructions regarding duration, dosage, tapering, and safety.
“Given the prevalence of concerns about potential adverse effects of topical-corticosteroids, it would seem prudent to signpost parents/carers towards convenient, consistent, evidence-based information to ensure that the potential negative impacts of seeking (unsubstantiated) medical advice online are minimized. In the absence of such information they are likely to turn to online discussion forums as their sole resource where, although much useful support and advice can be found, some is of questionable validity,” the investigators concluded.
Find the full study in the British Journal of Dermatology (doi: 10.1111/bjd.15130).
Many caregivers of children with atopic dermatitis do not receive clear instructions on how to properly use topical corticosteroids and seek advice on online forums, according to Emma Teasdale, PhD, and her associates.
The investigators analyzed 27 forum discussions involving 95 participants from 2003 to 2015 and found that parents expressed a range of beliefs regarding the use of topical corticosteroids. Some parents expressed positive views, but many were cautious and perceived topical corticosteroids as unnatural or too strong. Notably, parents said they believed that topical corticosteroids thinned or weakened the skin.
Parents also expressed uncertainty over how to use topical corticosteroids. Common questions involved duration of use, where and when to apply, and confusion over the strength of different preparations. Parents also noted that they received conflicting physician instructions regarding duration, dosage, tapering, and safety.
“Given the prevalence of concerns about potential adverse effects of topical-corticosteroids, it would seem prudent to signpost parents/carers towards convenient, consistent, evidence-based information to ensure that the potential negative impacts of seeking (unsubstantiated) medical advice online are minimized. In the absence of such information they are likely to turn to online discussion forums as their sole resource where, although much useful support and advice can be found, some is of questionable validity,” the investigators concluded.
Find the full study in the British Journal of Dermatology (doi: 10.1111/bjd.15130).
Many caregivers of children with atopic dermatitis do not receive clear instructions on how to properly use topical corticosteroids and seek advice on online forums, according to Emma Teasdale, PhD, and her associates.
The investigators analyzed 27 forum discussions involving 95 participants from 2003 to 2015 and found that parents expressed a range of beliefs regarding the use of topical corticosteroids. Some parents expressed positive views, but many were cautious and perceived topical corticosteroids as unnatural or too strong. Notably, parents said they believed that topical corticosteroids thinned or weakened the skin.
Parents also expressed uncertainty over how to use topical corticosteroids. Common questions involved duration of use, where and when to apply, and confusion over the strength of different preparations. Parents also noted that they received conflicting physician instructions regarding duration, dosage, tapering, and safety.
“Given the prevalence of concerns about potential adverse effects of topical-corticosteroids, it would seem prudent to signpost parents/carers towards convenient, consistent, evidence-based information to ensure that the potential negative impacts of seeking (unsubstantiated) medical advice online are minimized. In the absence of such information they are likely to turn to online discussion forums as their sole resource where, although much useful support and advice can be found, some is of questionable validity,” the investigators concluded.
Find the full study in the British Journal of Dermatology (doi: 10.1111/bjd.15130).
FROM THE BRITISH JOURNAL OF DERMATOLOGY
Restrict gluten if necessary, but confirm condition first
SAN FRANCISCO – Elimination diet crazes have been around for centuries, and one of today’s biggest targets is gluten, contributing to an industry of gluten-free products with revenue in the billions of dollars.
But does taking gluten off your child’s plate actually improve their health? It will if they have a condition in which gluten actually causes symptoms, explained Michelle M. Pietzak, MD, a pediatrician at the University of Southern California, Los Angeles.
Gluten is a mixture of proteins found in wheat, rye, barley, oats, corn, and rice that gives food its elasticity and helps dough rise. Only the gluten in wheat, rye, and barley causes gluten-related symptoms, but it is found in a variety of derivative products, such as spelt, kamut, triticale, couscous, bulgar, faro, matzo flour, and other grains as well. Oats are also considered cross-contaminated with gluten because they are milled with wheat, and other foods containing gluten may be difficult to identify due to food labeling and preparation practices in the United States.
For those with celiac disease, wheat allergy, irritable bowel syndrome (IBS), or nonceliac gluten sensitivity or intolerance, a gluten-free diet can reduce or eliminate the symptoms causing problems. For others, however, the symptoms likely come from somewhere besides gluten or may be a nocebo effect, where a patient who expects negative symptoms becomes more likely to have them.
Lactose intolerance is one example that can cause symptoms similar to those that respond to restricting gluten. Another is sensitivity to fructans, a wheat carbohydrate and one of the fermentable oligo-di-monosaccharides and polyols (FODMAPs) that can improve IBS when restricted. Imbalance in a person’s gut bacteria, called dysbiosis, also may cause similar symptoms and results from excess yeast, parasites, or an overgrowth of bad bacteria in the absence of beneficial ones.
Understanding celiac disease
This immune-mediated disease causes primarily gastrointestinal symptoms when someone ingests proteins called prolamines, which those with celiac disease are genetically predisposed to have difficulty digesting. Common symptoms include diarrhea, nausea, vomiting, abdominal pain, constipation, appetite changes, and, in unusual cases, excess fat in the feces (steatorrhea).
But celiac disease also may contribute to a short stature, osteoporosis, dermatitis herpetiformis, delayed onset of puberty, infertility, anemia (from iron and/or folic acid deficits), epilepsy, and behavioral changes. Although those with celiac disease are at a higher risk for arthritis, osteoporosis, osteopenia, osteomalacia, and rickets, a gluten-free diet can improve children’s low bone mineral density.
Screening for celiac disease includes testing for antigliadin (AGA) IgG and IgA, antiendomysial IgA, anti-tissue transglutaminase (tTG) IgA, total serum IgA, and genetic testing related to HLA-DQ2 and HLA-DQ8 genes.
Wheat allergy
A wheat allergy, among the eight most common food allergies, involves an IgE-mediated reaction to water- and salt-insoluble gliadins, especially omega-5 gliadin, which can cause anaphylaxis in a wheat-allergic person who exercises after ingesting wheat. Symptoms of wheat allergy include hives; swelling, itching or irritation of the mouth, throat, eyes, and nose; difficulty breathing; and cramps, nausea, vomiting, and diarrhea. Wheat allergy most commonly occurs in infants or toddlers, and typically co-occurs with other food allergies, but children usually outgrow the allergy by ages 3-5 years.
Nonceliac gluten sensitivity or intolerance
Physicians only should consider gluten insensitivity or intolerance after ruling out celiac disease and wheat allergy. Less understood and more controversial, gluten sensitivity or intolerance may be an immune-mediated condition – or instead an intestinal malfunction. Some patients may simply have an intolerance to high fiber foods in general. Patients with this sensitivity or intolerance will have a normal intestinal biopsy, but AGA IgG and/or IgA testing and genetic HLA-DQ2 testing may be positive. The clinical diagnosis is ultimately one of exclusion determined when a gluten-free diet alleviates symptoms.
Although gas, diarrhea, weight loss, and abdominal pain are the most common symptoms, other transient symptoms may include dyspepsia, nausea, vomiting, bloating, constipation, intestinal rumbling, joint or bone pain, muscle cramps or pain, fatigue, numbness, cramps, headaches, rashes, tongue inflammation, anemia, leg numbness, osteoporosis, or unexplained anemia.
Another potential effect of gluten sensitivity is dermatitis herpetiformis, a skin inflammation involving blisters, hives, or other types of erythematous or urticarial papules, usually symmetrically distributed, with severe itching. Although 90% of individuals with dermatitis herpetiformis lack any gastrointestinal symptoms, about 75% have villous atrophy, Dr. Pietzak said.
Even less understood are neurologic symptoms of gluten sensitivity and their potential mechanisms. Reported neurologic findings of gluten sensitivity include ataxia, peripheral neuropathy, depression, schizophrenia, epilepsy, and intracranial calcifications.
Irritable bowel syndrome
The similarity of symptoms between IBS and celiac disease has meant many with celiac disease were misdiagnosed with IBS, particularly women, Dr. Pietzak said. To confuse matters more, restricting gluten has shown improvement in IBS symptoms for some patients: in one study, 60% of those with diarrhea returned to having normal stools after 6 months of a gluten-free diet. Again, AGA IgG and tTG IgG testing was more likely to be positive among these patients. IBS and celiac disease can co-occur in patients, but it’s necessary to rule out celiac disease before diagnosing a patient with IBS.
Importance of differential diagnosis
It’s important to know the difference between celiac disease and other conditions because patients may face different risks even if their treatment is similar. Those with celiac disease, for example, have a greater risk of nutritional deficiencies leading to conditions such as iron-deficiency anemia and osteoporosis, and are more likely to develop gastrointestinal cancers or other autoimmune conditions, such as thyroid disease, type 1 diabetes, joint diseases, and liver diseases.
Those with food allergies and intolerances do not share those increased risks, and their symptoms resolve without long-term organ damage when they remove the gluten or wheat from their diet. Further, only those with celiac disease must restrict all foods with gluten. Those with a wheat allergy may be able to eat rye, barley, and oats, for example, and restricting gluten may improve IBS symptoms for only a subset of patients.
Dr. Pietzak has consulted for Nestle Nutrition and is on the speaker’s bureau for Prometheus Labs, a lab which does business in testing for celiac disease.
SAN FRANCISCO – Elimination diet crazes have been around for centuries, and one of today’s biggest targets is gluten, contributing to an industry of gluten-free products with revenue in the billions of dollars.
But does taking gluten off your child’s plate actually improve their health? It will if they have a condition in which gluten actually causes symptoms, explained Michelle M. Pietzak, MD, a pediatrician at the University of Southern California, Los Angeles.
Gluten is a mixture of proteins found in wheat, rye, barley, oats, corn, and rice that gives food its elasticity and helps dough rise. Only the gluten in wheat, rye, and barley causes gluten-related symptoms, but it is found in a variety of derivative products, such as spelt, kamut, triticale, couscous, bulgar, faro, matzo flour, and other grains as well. Oats are also considered cross-contaminated with gluten because they are milled with wheat, and other foods containing gluten may be difficult to identify due to food labeling and preparation practices in the United States.
For those with celiac disease, wheat allergy, irritable bowel syndrome (IBS), or nonceliac gluten sensitivity or intolerance, a gluten-free diet can reduce or eliminate the symptoms causing problems. For others, however, the symptoms likely come from somewhere besides gluten or may be a nocebo effect, where a patient who expects negative symptoms becomes more likely to have them.
Lactose intolerance is one example that can cause symptoms similar to those that respond to restricting gluten. Another is sensitivity to fructans, a wheat carbohydrate and one of the fermentable oligo-di-monosaccharides and polyols (FODMAPs) that can improve IBS when restricted. Imbalance in a person’s gut bacteria, called dysbiosis, also may cause similar symptoms and results from excess yeast, parasites, or an overgrowth of bad bacteria in the absence of beneficial ones.
Understanding celiac disease
This immune-mediated disease causes primarily gastrointestinal symptoms when someone ingests proteins called prolamines, which those with celiac disease are genetically predisposed to have difficulty digesting. Common symptoms include diarrhea, nausea, vomiting, abdominal pain, constipation, appetite changes, and, in unusual cases, excess fat in the feces (steatorrhea).
But celiac disease also may contribute to a short stature, osteoporosis, dermatitis herpetiformis, delayed onset of puberty, infertility, anemia (from iron and/or folic acid deficits), epilepsy, and behavioral changes. Although those with celiac disease are at a higher risk for arthritis, osteoporosis, osteopenia, osteomalacia, and rickets, a gluten-free diet can improve children’s low bone mineral density.
Screening for celiac disease includes testing for antigliadin (AGA) IgG and IgA, antiendomysial IgA, anti-tissue transglutaminase (tTG) IgA, total serum IgA, and genetic testing related to HLA-DQ2 and HLA-DQ8 genes.
Wheat allergy
A wheat allergy, among the eight most common food allergies, involves an IgE-mediated reaction to water- and salt-insoluble gliadins, especially omega-5 gliadin, which can cause anaphylaxis in a wheat-allergic person who exercises after ingesting wheat. Symptoms of wheat allergy include hives; swelling, itching or irritation of the mouth, throat, eyes, and nose; difficulty breathing; and cramps, nausea, vomiting, and diarrhea. Wheat allergy most commonly occurs in infants or toddlers, and typically co-occurs with other food allergies, but children usually outgrow the allergy by ages 3-5 years.
Nonceliac gluten sensitivity or intolerance
Physicians only should consider gluten insensitivity or intolerance after ruling out celiac disease and wheat allergy. Less understood and more controversial, gluten sensitivity or intolerance may be an immune-mediated condition – or instead an intestinal malfunction. Some patients may simply have an intolerance to high fiber foods in general. Patients with this sensitivity or intolerance will have a normal intestinal biopsy, but AGA IgG and/or IgA testing and genetic HLA-DQ2 testing may be positive. The clinical diagnosis is ultimately one of exclusion determined when a gluten-free diet alleviates symptoms.
Although gas, diarrhea, weight loss, and abdominal pain are the most common symptoms, other transient symptoms may include dyspepsia, nausea, vomiting, bloating, constipation, intestinal rumbling, joint or bone pain, muscle cramps or pain, fatigue, numbness, cramps, headaches, rashes, tongue inflammation, anemia, leg numbness, osteoporosis, or unexplained anemia.
Another potential effect of gluten sensitivity is dermatitis herpetiformis, a skin inflammation involving blisters, hives, or other types of erythematous or urticarial papules, usually symmetrically distributed, with severe itching. Although 90% of individuals with dermatitis herpetiformis lack any gastrointestinal symptoms, about 75% have villous atrophy, Dr. Pietzak said.
Even less understood are neurologic symptoms of gluten sensitivity and their potential mechanisms. Reported neurologic findings of gluten sensitivity include ataxia, peripheral neuropathy, depression, schizophrenia, epilepsy, and intracranial calcifications.
Irritable bowel syndrome
The similarity of symptoms between IBS and celiac disease has meant many with celiac disease were misdiagnosed with IBS, particularly women, Dr. Pietzak said. To confuse matters more, restricting gluten has shown improvement in IBS symptoms for some patients: in one study, 60% of those with diarrhea returned to having normal stools after 6 months of a gluten-free diet. Again, AGA IgG and tTG IgG testing was more likely to be positive among these patients. IBS and celiac disease can co-occur in patients, but it’s necessary to rule out celiac disease before diagnosing a patient with IBS.
Importance of differential diagnosis
It’s important to know the difference between celiac disease and other conditions because patients may face different risks even if their treatment is similar. Those with celiac disease, for example, have a greater risk of nutritional deficiencies leading to conditions such as iron-deficiency anemia and osteoporosis, and are more likely to develop gastrointestinal cancers or other autoimmune conditions, such as thyroid disease, type 1 diabetes, joint diseases, and liver diseases.
Those with food allergies and intolerances do not share those increased risks, and their symptoms resolve without long-term organ damage when they remove the gluten or wheat from their diet. Further, only those with celiac disease must restrict all foods with gluten. Those with a wheat allergy may be able to eat rye, barley, and oats, for example, and restricting gluten may improve IBS symptoms for only a subset of patients.
Dr. Pietzak has consulted for Nestle Nutrition and is on the speaker’s bureau for Prometheus Labs, a lab which does business in testing for celiac disease.
SAN FRANCISCO – Elimination diet crazes have been around for centuries, and one of today’s biggest targets is gluten, contributing to an industry of gluten-free products with revenue in the billions of dollars.
But does taking gluten off your child’s plate actually improve their health? It will if they have a condition in which gluten actually causes symptoms, explained Michelle M. Pietzak, MD, a pediatrician at the University of Southern California, Los Angeles.
Gluten is a mixture of proteins found in wheat, rye, barley, oats, corn, and rice that gives food its elasticity and helps dough rise. Only the gluten in wheat, rye, and barley causes gluten-related symptoms, but it is found in a variety of derivative products, such as spelt, kamut, triticale, couscous, bulgar, faro, matzo flour, and other grains as well. Oats are also considered cross-contaminated with gluten because they are milled with wheat, and other foods containing gluten may be difficult to identify due to food labeling and preparation practices in the United States.
For those with celiac disease, wheat allergy, irritable bowel syndrome (IBS), or nonceliac gluten sensitivity or intolerance, a gluten-free diet can reduce or eliminate the symptoms causing problems. For others, however, the symptoms likely come from somewhere besides gluten or may be a nocebo effect, where a patient who expects negative symptoms becomes more likely to have them.
Lactose intolerance is one example that can cause symptoms similar to those that respond to restricting gluten. Another is sensitivity to fructans, a wheat carbohydrate and one of the fermentable oligo-di-monosaccharides and polyols (FODMAPs) that can improve IBS when restricted. Imbalance in a person’s gut bacteria, called dysbiosis, also may cause similar symptoms and results from excess yeast, parasites, or an overgrowth of bad bacteria in the absence of beneficial ones.
Understanding celiac disease
This immune-mediated disease causes primarily gastrointestinal symptoms when someone ingests proteins called prolamines, which those with celiac disease are genetically predisposed to have difficulty digesting. Common symptoms include diarrhea, nausea, vomiting, abdominal pain, constipation, appetite changes, and, in unusual cases, excess fat in the feces (steatorrhea).
But celiac disease also may contribute to a short stature, osteoporosis, dermatitis herpetiformis, delayed onset of puberty, infertility, anemia (from iron and/or folic acid deficits), epilepsy, and behavioral changes. Although those with celiac disease are at a higher risk for arthritis, osteoporosis, osteopenia, osteomalacia, and rickets, a gluten-free diet can improve children’s low bone mineral density.
Screening for celiac disease includes testing for antigliadin (AGA) IgG and IgA, antiendomysial IgA, anti-tissue transglutaminase (tTG) IgA, total serum IgA, and genetic testing related to HLA-DQ2 and HLA-DQ8 genes.
Wheat allergy
A wheat allergy, among the eight most common food allergies, involves an IgE-mediated reaction to water- and salt-insoluble gliadins, especially omega-5 gliadin, which can cause anaphylaxis in a wheat-allergic person who exercises after ingesting wheat. Symptoms of wheat allergy include hives; swelling, itching or irritation of the mouth, throat, eyes, and nose; difficulty breathing; and cramps, nausea, vomiting, and diarrhea. Wheat allergy most commonly occurs in infants or toddlers, and typically co-occurs with other food allergies, but children usually outgrow the allergy by ages 3-5 years.
Nonceliac gluten sensitivity or intolerance
Physicians only should consider gluten insensitivity or intolerance after ruling out celiac disease and wheat allergy. Less understood and more controversial, gluten sensitivity or intolerance may be an immune-mediated condition – or instead an intestinal malfunction. Some patients may simply have an intolerance to high fiber foods in general. Patients with this sensitivity or intolerance will have a normal intestinal biopsy, but AGA IgG and/or IgA testing and genetic HLA-DQ2 testing may be positive. The clinical diagnosis is ultimately one of exclusion determined when a gluten-free diet alleviates symptoms.
Although gas, diarrhea, weight loss, and abdominal pain are the most common symptoms, other transient symptoms may include dyspepsia, nausea, vomiting, bloating, constipation, intestinal rumbling, joint or bone pain, muscle cramps or pain, fatigue, numbness, cramps, headaches, rashes, tongue inflammation, anemia, leg numbness, osteoporosis, or unexplained anemia.
Another potential effect of gluten sensitivity is dermatitis herpetiformis, a skin inflammation involving blisters, hives, or other types of erythematous or urticarial papules, usually symmetrically distributed, with severe itching. Although 90% of individuals with dermatitis herpetiformis lack any gastrointestinal symptoms, about 75% have villous atrophy, Dr. Pietzak said.
Even less understood are neurologic symptoms of gluten sensitivity and their potential mechanisms. Reported neurologic findings of gluten sensitivity include ataxia, peripheral neuropathy, depression, schizophrenia, epilepsy, and intracranial calcifications.
Irritable bowel syndrome
The similarity of symptoms between IBS and celiac disease has meant many with celiac disease were misdiagnosed with IBS, particularly women, Dr. Pietzak said. To confuse matters more, restricting gluten has shown improvement in IBS symptoms for some patients: in one study, 60% of those with diarrhea returned to having normal stools after 6 months of a gluten-free diet. Again, AGA IgG and tTG IgG testing was more likely to be positive among these patients. IBS and celiac disease can co-occur in patients, but it’s necessary to rule out celiac disease before diagnosing a patient with IBS.
Importance of differential diagnosis
It’s important to know the difference between celiac disease and other conditions because patients may face different risks even if their treatment is similar. Those with celiac disease, for example, have a greater risk of nutritional deficiencies leading to conditions such as iron-deficiency anemia and osteoporosis, and are more likely to develop gastrointestinal cancers or other autoimmune conditions, such as thyroid disease, type 1 diabetes, joint diseases, and liver diseases.
Those with food allergies and intolerances do not share those increased risks, and their symptoms resolve without long-term organ damage when they remove the gluten or wheat from their diet. Further, only those with celiac disease must restrict all foods with gluten. Those with a wheat allergy may be able to eat rye, barley, and oats, for example, and restricting gluten may improve IBS symptoms for only a subset of patients.
Dr. Pietzak has consulted for Nestle Nutrition and is on the speaker’s bureau for Prometheus Labs, a lab which does business in testing for celiac disease.
EXPERT ANALYSIS FROM AAP 16
Rate of resistant P. aeruginosa in children rising steadily
The rate of infection with resistant Pseudomonas aeruginosa among children has risen steadily about 4% per year since 1999, according to a report.
Infections with P aeruginosa in children occur most often associated with pulmonary disease in patients with cystic fibrosis, but healthy children also can experience a variety of P aeruginosa infection types.
They focused on 77,349 P. aeruginosa isolates that were tested for resistance for all five antibiotic classes: cephalosporins, beta-lactam and beta-lactamase inhibitors, carbapenems, fluoroquinolones, and aminoglycosides. The investigators were specifically interested in multidrug- and carbapenem-resistant P. aeruginosa. They described the organism as “arguably the most resistance-prone health care–related pathogen.”
The study samples were obtained from the respiratory tract, urinary tract, ear, sinuses, wounds, skin, and connective tissues of children aged 1-17 years who were treated in 1999-2012; 2012 was the last year for which this information was collected in this database. Patients were treated in ambulatory, inpatient, ICU, and long-term-care settings. The study excluded children with cystic fibrosis and children under 1 year of age, so as to improve the applicability of the results to the general pediatric population.
The proportion of multidrug-resistant P. aeruginosa samples rose from 15% to 26% during the 13-year study period, and the proportion of carbapenem-resistant P. aeruginosa samples rose from 9% to 20%. This represents an average annual increase of approximately 4% for both types of resistance, Dr. Logan and her associates said (J Ped Infect Dis. 2016 Nov 16. doi: 10.1093/jpids/piw064).
These increases were consistent across all but one age group and all but one treatment setting, the exception being inpatients aged 13-17 years. The prevalence of resistant P. aeruginosa was highest among adolescents in ambulatory, ICU, or long-term-care settings; their rates were three times higher than those in children aged 1 year and two times higher than those in children aged 5 years. It is possible that this pattern reflects “an increasing number of older children with a medically complex condition who have frequent exposure to the health care environment,” the investigators noted.
“The results of our study highlight the need for bacterial surveillance, strategies for implementing effective infection prevention, and antimicrobial stewardship programs.” In addition, all health care facilities should consider using rapid molecular diagnostic platforms to guide antibiotic treatment decisions, “to reduce the burden of the persistent and continually evolving global threat of extensively drug-resistant organisms,” Dr. Logan and her associates added.
This study was supported by the National Institute of Allergy and Infectious Diseases; the Global Antibiotic Resistance Partnership, funded by the Bill and Melinda Gates Foundation; and the Health Grand Challenges Program at Princeton University. Dr. Logan and her associates reported having no relevant financial disclosures.
The rate of infection with resistant Pseudomonas aeruginosa among children has risen steadily about 4% per year since 1999, according to a report.
Infections with P aeruginosa in children occur most often associated with pulmonary disease in patients with cystic fibrosis, but healthy children also can experience a variety of P aeruginosa infection types.
They focused on 77,349 P. aeruginosa isolates that were tested for resistance for all five antibiotic classes: cephalosporins, beta-lactam and beta-lactamase inhibitors, carbapenems, fluoroquinolones, and aminoglycosides. The investigators were specifically interested in multidrug- and carbapenem-resistant P. aeruginosa. They described the organism as “arguably the most resistance-prone health care–related pathogen.”
The study samples were obtained from the respiratory tract, urinary tract, ear, sinuses, wounds, skin, and connective tissues of children aged 1-17 years who were treated in 1999-2012; 2012 was the last year for which this information was collected in this database. Patients were treated in ambulatory, inpatient, ICU, and long-term-care settings. The study excluded children with cystic fibrosis and children under 1 year of age, so as to improve the applicability of the results to the general pediatric population.
The proportion of multidrug-resistant P. aeruginosa samples rose from 15% to 26% during the 13-year study period, and the proportion of carbapenem-resistant P. aeruginosa samples rose from 9% to 20%. This represents an average annual increase of approximately 4% for both types of resistance, Dr. Logan and her associates said (J Ped Infect Dis. 2016 Nov 16. doi: 10.1093/jpids/piw064).
These increases were consistent across all but one age group and all but one treatment setting, the exception being inpatients aged 13-17 years. The prevalence of resistant P. aeruginosa was highest among adolescents in ambulatory, ICU, or long-term-care settings; their rates were three times higher than those in children aged 1 year and two times higher than those in children aged 5 years. It is possible that this pattern reflects “an increasing number of older children with a medically complex condition who have frequent exposure to the health care environment,” the investigators noted.
“The results of our study highlight the need for bacterial surveillance, strategies for implementing effective infection prevention, and antimicrobial stewardship programs.” In addition, all health care facilities should consider using rapid molecular diagnostic platforms to guide antibiotic treatment decisions, “to reduce the burden of the persistent and continually evolving global threat of extensively drug-resistant organisms,” Dr. Logan and her associates added.
This study was supported by the National Institute of Allergy and Infectious Diseases; the Global Antibiotic Resistance Partnership, funded by the Bill and Melinda Gates Foundation; and the Health Grand Challenges Program at Princeton University. Dr. Logan and her associates reported having no relevant financial disclosures.
The rate of infection with resistant Pseudomonas aeruginosa among children has risen steadily about 4% per year since 1999, according to a report.
Infections with P aeruginosa in children occur most often associated with pulmonary disease in patients with cystic fibrosis, but healthy children also can experience a variety of P aeruginosa infection types.
They focused on 77,349 P. aeruginosa isolates that were tested for resistance for all five antibiotic classes: cephalosporins, beta-lactam and beta-lactamase inhibitors, carbapenems, fluoroquinolones, and aminoglycosides. The investigators were specifically interested in multidrug- and carbapenem-resistant P. aeruginosa. They described the organism as “arguably the most resistance-prone health care–related pathogen.”
The study samples were obtained from the respiratory tract, urinary tract, ear, sinuses, wounds, skin, and connective tissues of children aged 1-17 years who were treated in 1999-2012; 2012 was the last year for which this information was collected in this database. Patients were treated in ambulatory, inpatient, ICU, and long-term-care settings. The study excluded children with cystic fibrosis and children under 1 year of age, so as to improve the applicability of the results to the general pediatric population.
The proportion of multidrug-resistant P. aeruginosa samples rose from 15% to 26% during the 13-year study period, and the proportion of carbapenem-resistant P. aeruginosa samples rose from 9% to 20%. This represents an average annual increase of approximately 4% for both types of resistance, Dr. Logan and her associates said (J Ped Infect Dis. 2016 Nov 16. doi: 10.1093/jpids/piw064).
These increases were consistent across all but one age group and all but one treatment setting, the exception being inpatients aged 13-17 years. The prevalence of resistant P. aeruginosa was highest among adolescents in ambulatory, ICU, or long-term-care settings; their rates were three times higher than those in children aged 1 year and two times higher than those in children aged 5 years. It is possible that this pattern reflects “an increasing number of older children with a medically complex condition who have frequent exposure to the health care environment,” the investigators noted.
“The results of our study highlight the need for bacterial surveillance, strategies for implementing effective infection prevention, and antimicrobial stewardship programs.” In addition, all health care facilities should consider using rapid molecular diagnostic platforms to guide antibiotic treatment decisions, “to reduce the burden of the persistent and continually evolving global threat of extensively drug-resistant organisms,” Dr. Logan and her associates added.
This study was supported by the National Institute of Allergy and Infectious Diseases; the Global Antibiotic Resistance Partnership, funded by the Bill and Melinda Gates Foundation; and the Health Grand Challenges Program at Princeton University. Dr. Logan and her associates reported having no relevant financial disclosures.
FROM THE JOURNAL OF PEDIATRIC INFECTIOUS DISEASES
Key clinical point:
Major finding: The proportion of multidrug-resistant P. aeruginosa samples rose from 15% to 26% during the 13-year study period, and the proportion of carbapenem-resistant P. aeruginosa samples rose from 9% to 20%.
Data source: A longitudinal analysis of information in a nationally representative database of microbiology laboratories serving approximately 300 U.S. hospitals.
Disclosures: This study was supported by the National Institute of Allergy and Infectious Diseases; the Global Antibiotic Resistance Partnership, funded by the Bill and Melinda Gates Foundation; and the Health Grand Challenges Program at Princeton University. Dr. Logan and her associates reported having no relevant financial disclosures.
How social media solved a skin outbreak
Several teens who came home from a trip abroad with ugly ulcerated skin lesions in 2014 got vague and unhelpful diagnoses: Physicians thought they had bug bites. True, but that was only part of the story. It took an alert dermatologist and Facebook to identify the true cause, spread the word, and stop the outbreak.
“Social media facilitated communication between patients, crowd sourcing a diagnosis,” said Kanokporn Mongkolrattanothai, MD, who treated three of the teens at Children’s Hospital Los Angeles.
What did the kids have? Read on and see if you can make the diagnosis yourself.
Upon their return, pruritic red papules appeared on a 16-year-old girl’s ankle and thigh. They transformed into ulcers with raised edges and a central crater, according to a report that published online in Pediatric Dermatology (2016 Sep;33[5]:e276-7. doi: 10.1111/pde.12910). At least 12 teens from the trip had similar ulcerated lesions, mostly in exposed areas like arms and legs, said Dr. Mongkolrattanothai, an infectious disease specialist at Children’s Hospital Los Angeles and a coauthor of the report.
Six patients received a diagnosis of insect bites, and one was diagnosed with a bacterial skin infection, noted Dr. Mongkolrattanothai of the University of Southern California, Los Angeles. But these diagnoses were incorrect.
“The light bulb really came on when she mentioned that the lesions were still present several months after the trip to Israel,” said Dr. Krakowski, who was at Rady Children’s Hospital–San Diego at the time. “On physical exam, the lesions were ulcerated and eroded and did not look to be typical bug bite reactions.” The Centers for Disease Control and Prevention confirmed the diagnosis.
On Facebook, the teenager posted a picture of a T-shirt with the words “I went to Israel, and all I got was leishmaniasis.” At the same time, another traveler on the same trip posted pictures of lesions. This set off a wave of awareness that sent affected teens to seek care at Children’s Hospital Los Angeles, Mattel Children’s Hospital UCLA, Cedars-Sinai Medical Center, Kaiser Permanente Woodland Hills Medical Center, and Rady Children’s Hospital–San Diego.
“It is likely that our patients became infected with leishmaniasis while camping in the Negev Desert, sleeping on sand dunes at night without use of mosquito netting or tents,” Dr. Mongkolrattanothai said in an interview. “Most of the affected teens did not take precautions against insect bites, which would have included appropriate clothing to minimize areas of exposed skin and the use of repellent products. This placed them at risk for sand fly bites, as sand flies are most active in twilight, evening, and nighttime hours.”
Cutaneous leishmaniasis can lead to permanent scarring, and another form, visceral leishmaniasis, can be fatal.
What helped Dr. Krakowski crack the case? “Training at the University of California at San Diego, in such close proximity to the Navy’s Balboa Medical Center, we are taught from day 1 to think outside of the box because ‘there are zebras in Africa,’ ” he said. “With so much international travel in and out of the region, including to locations where leishmaniasis is endemic, it is warranted to consider that specific diagnosis on the differential. Normally, I do not have to biopsy ‘bug bites,’ but considering the patient’s entire presentation, you almost have to do a biopsy to make sure the lesions were not leishmaniasis.”
Dr. Krakowski praised the CDC. “They have a tremendous amount of resources dedicated to helping investigators work through diagnostic dilemmas such as this, and they helped us – free of charge – to confirm the diagnosis, type the leishmaniasis, and plot a treatment course to resolution,” he said. “They also were instrumental in helping us identify and educate other potentially exposed patients from the camping trip.”
In November, the Infectious Diseases Society of America and the American Society of Tropical Medicine and Hygiene published new guidelines about leishmaniasis in Clinical Infectious Diseases (doi: 10.1093/cid/ciw670). The societies warn that leishmaniasis is becoming more common in the United States, in part because of ecotourists infected in Central and South America and returning soldiers infected in Afghanistan and Iraq.
Dr. Mongkolrattanothai and Dr. Krakowski reported no relevant financial disclosures.
Several teens who came home from a trip abroad with ugly ulcerated skin lesions in 2014 got vague and unhelpful diagnoses: Physicians thought they had bug bites. True, but that was only part of the story. It took an alert dermatologist and Facebook to identify the true cause, spread the word, and stop the outbreak.
“Social media facilitated communication between patients, crowd sourcing a diagnosis,” said Kanokporn Mongkolrattanothai, MD, who treated three of the teens at Children’s Hospital Los Angeles.
What did the kids have? Read on and see if you can make the diagnosis yourself.
Upon their return, pruritic red papules appeared on a 16-year-old girl’s ankle and thigh. They transformed into ulcers with raised edges and a central crater, according to a report that published online in Pediatric Dermatology (2016 Sep;33[5]:e276-7. doi: 10.1111/pde.12910). At least 12 teens from the trip had similar ulcerated lesions, mostly in exposed areas like arms and legs, said Dr. Mongkolrattanothai, an infectious disease specialist at Children’s Hospital Los Angeles and a coauthor of the report.
Six patients received a diagnosis of insect bites, and one was diagnosed with a bacterial skin infection, noted Dr. Mongkolrattanothai of the University of Southern California, Los Angeles. But these diagnoses were incorrect.
“The light bulb really came on when she mentioned that the lesions were still present several months after the trip to Israel,” said Dr. Krakowski, who was at Rady Children’s Hospital–San Diego at the time. “On physical exam, the lesions were ulcerated and eroded and did not look to be typical bug bite reactions.” The Centers for Disease Control and Prevention confirmed the diagnosis.
On Facebook, the teenager posted a picture of a T-shirt with the words “I went to Israel, and all I got was leishmaniasis.” At the same time, another traveler on the same trip posted pictures of lesions. This set off a wave of awareness that sent affected teens to seek care at Children’s Hospital Los Angeles, Mattel Children’s Hospital UCLA, Cedars-Sinai Medical Center, Kaiser Permanente Woodland Hills Medical Center, and Rady Children’s Hospital–San Diego.
“It is likely that our patients became infected with leishmaniasis while camping in the Negev Desert, sleeping on sand dunes at night without use of mosquito netting or tents,” Dr. Mongkolrattanothai said in an interview. “Most of the affected teens did not take precautions against insect bites, which would have included appropriate clothing to minimize areas of exposed skin and the use of repellent products. This placed them at risk for sand fly bites, as sand flies are most active in twilight, evening, and nighttime hours.”
Cutaneous leishmaniasis can lead to permanent scarring, and another form, visceral leishmaniasis, can be fatal.
What helped Dr. Krakowski crack the case? “Training at the University of California at San Diego, in such close proximity to the Navy’s Balboa Medical Center, we are taught from day 1 to think outside of the box because ‘there are zebras in Africa,’ ” he said. “With so much international travel in and out of the region, including to locations where leishmaniasis is endemic, it is warranted to consider that specific diagnosis on the differential. Normally, I do not have to biopsy ‘bug bites,’ but considering the patient’s entire presentation, you almost have to do a biopsy to make sure the lesions were not leishmaniasis.”
Dr. Krakowski praised the CDC. “They have a tremendous amount of resources dedicated to helping investigators work through diagnostic dilemmas such as this, and they helped us – free of charge – to confirm the diagnosis, type the leishmaniasis, and plot a treatment course to resolution,” he said. “They also were instrumental in helping us identify and educate other potentially exposed patients from the camping trip.”
In November, the Infectious Diseases Society of America and the American Society of Tropical Medicine and Hygiene published new guidelines about leishmaniasis in Clinical Infectious Diseases (doi: 10.1093/cid/ciw670). The societies warn that leishmaniasis is becoming more common in the United States, in part because of ecotourists infected in Central and South America and returning soldiers infected in Afghanistan and Iraq.
Dr. Mongkolrattanothai and Dr. Krakowski reported no relevant financial disclosures.
Several teens who came home from a trip abroad with ugly ulcerated skin lesions in 2014 got vague and unhelpful diagnoses: Physicians thought they had bug bites. True, but that was only part of the story. It took an alert dermatologist and Facebook to identify the true cause, spread the word, and stop the outbreak.
“Social media facilitated communication between patients, crowd sourcing a diagnosis,” said Kanokporn Mongkolrattanothai, MD, who treated three of the teens at Children’s Hospital Los Angeles.
What did the kids have? Read on and see if you can make the diagnosis yourself.
Upon their return, pruritic red papules appeared on a 16-year-old girl’s ankle and thigh. They transformed into ulcers with raised edges and a central crater, according to a report that published online in Pediatric Dermatology (2016 Sep;33[5]:e276-7. doi: 10.1111/pde.12910). At least 12 teens from the trip had similar ulcerated lesions, mostly in exposed areas like arms and legs, said Dr. Mongkolrattanothai, an infectious disease specialist at Children’s Hospital Los Angeles and a coauthor of the report.
Six patients received a diagnosis of insect bites, and one was diagnosed with a bacterial skin infection, noted Dr. Mongkolrattanothai of the University of Southern California, Los Angeles. But these diagnoses were incorrect.
“The light bulb really came on when she mentioned that the lesions were still present several months after the trip to Israel,” said Dr. Krakowski, who was at Rady Children’s Hospital–San Diego at the time. “On physical exam, the lesions were ulcerated and eroded and did not look to be typical bug bite reactions.” The Centers for Disease Control and Prevention confirmed the diagnosis.
On Facebook, the teenager posted a picture of a T-shirt with the words “I went to Israel, and all I got was leishmaniasis.” At the same time, another traveler on the same trip posted pictures of lesions. This set off a wave of awareness that sent affected teens to seek care at Children’s Hospital Los Angeles, Mattel Children’s Hospital UCLA, Cedars-Sinai Medical Center, Kaiser Permanente Woodland Hills Medical Center, and Rady Children’s Hospital–San Diego.
“It is likely that our patients became infected with leishmaniasis while camping in the Negev Desert, sleeping on sand dunes at night without use of mosquito netting or tents,” Dr. Mongkolrattanothai said in an interview. “Most of the affected teens did not take precautions against insect bites, which would have included appropriate clothing to minimize areas of exposed skin and the use of repellent products. This placed them at risk for sand fly bites, as sand flies are most active in twilight, evening, and nighttime hours.”
Cutaneous leishmaniasis can lead to permanent scarring, and another form, visceral leishmaniasis, can be fatal.
What helped Dr. Krakowski crack the case? “Training at the University of California at San Diego, in such close proximity to the Navy’s Balboa Medical Center, we are taught from day 1 to think outside of the box because ‘there are zebras in Africa,’ ” he said. “With so much international travel in and out of the region, including to locations where leishmaniasis is endemic, it is warranted to consider that specific diagnosis on the differential. Normally, I do not have to biopsy ‘bug bites,’ but considering the patient’s entire presentation, you almost have to do a biopsy to make sure the lesions were not leishmaniasis.”
Dr. Krakowski praised the CDC. “They have a tremendous amount of resources dedicated to helping investigators work through diagnostic dilemmas such as this, and they helped us – free of charge – to confirm the diagnosis, type the leishmaniasis, and plot a treatment course to resolution,” he said. “They also were instrumental in helping us identify and educate other potentially exposed patients from the camping trip.”
In November, the Infectious Diseases Society of America and the American Society of Tropical Medicine and Hygiene published new guidelines about leishmaniasis in Clinical Infectious Diseases (doi: 10.1093/cid/ciw670). The societies warn that leishmaniasis is becoming more common in the United States, in part because of ecotourists infected in Central and South America and returning soldiers infected in Afghanistan and Iraq.
Dr. Mongkolrattanothai and Dr. Krakowski reported no relevant financial disclosures.
Influences and beliefs on vaccine hesitancy remain complex
ATLANTA – Before clinicians can learn new and effective strategies on addressing vaccine hesitancy in their practices, they need to understand both the “forest” and the “trees.” That is, it helps to understand the big picture in terms of national trends, and it’s equally important to understand the motivations and psychology of parents who refuse or remain hesitant about vaccines.
Paula Frew, PhD, MPH, of Emory University in Atlanta, pointed out that vaccination coverage of children under 3 years old in the United States remains consistently high. An estimated 93% of children have received at least three doses of the polio vaccine, 92% have received at least one dose of the MMR vaccine, 92% have received at least three doses of the hepatitis B vaccine, and 91% have received at least one dose of the varicella vaccine.
In fact, less than 1% of parents selectively or completely refuse all vaccines – but an estimated 13%-22% of parents intentionally delay vaccines, Dr. Frew said at a conference sponsored by the Centers for Disease Control and Prevention..
She described findings from a study she and colleagues conducted to assess the influence of vaccination decisions among parents of children under age 7 years. They categorized the parents as nonhesitant acceptors of vaccines, hesitant acceptors, delayers, or refusers. Surveys of 2,603 parents in 2012 and 2,518 parents in 2014 revealed that parents overwhelmingly cite their health care provider as their most trusted source of information on vaccines, including 99% of acceptors and 71% of refusers. Among hesitant acceptors, 49% of parents in 2012 and 48% of parents in 2014 said their doctor positively influenced their vaccination decision.
Qualitative findings from focus groups
Still, hesitancy is common enough that qualitative research is seeking to understand parents’ vaccine concerns. One such study involved focus groups with vaccine-hesitant mothers because mothers or other female guardians are the caregivers most often involved in their children’s health care decisions, according to Judith Mendel, MPH, of the U.S. Department of Health and Human Services.
Ms. Mendel’s study aimed to understand what drives vaccine-related confidence, how to overcome hesitancy over vaccines, and what messaging approaches might work most effectively. She and her colleagues recruited 61 women who participated in one of four groups in the Philadelphia area or one of four in the San Francisco area during April and May 2016. The women all were responsible for the health decisions of at least one child age 5 years or younger and had previously delayed or declined a recommended vaccine for their child.
Each group included six to nine women and involved a 2-hour semistructured discussion about health concerns; what vaccine confidence is; the mothers’ knowledge, attitudes, and beliefs about vaccines and immunization; and feedback on videos and info-graphics designed to educate others about immunization. The focus groups defined having confidence about vaccines as feeling trust, feeling good about a decision, having many years of research or practice, and being informed and knowledgeable.
“Three themes bubbled up together from the groups,” Ms. Mendel said. “Women had concerns about vaccine ingredients and their effects on physiology, about the recommended schedule, and about the medical system.”
Their concerns about vaccine ingredients and physiology would be familiar to pediatric providers:
• A persistent belief that autism is caused by vaccines.
• Concerns about vaccines made from weakened pathogens.
• Belief that vaccines replace a function that the body is equipped to handle on its own.
• Fears about short-term and long-term side effects.
• Little tolerance for established minor reactions to vaccines.
The mothers were accepting of the vaccines that had been on the schedule when they were children, such as polio, but they did not understand why vaccination starts so young and preferred “alternative” or catch-up schedules.
“They believed that when they were younger, the schedule started later,” Ms. Mendel said. “Some women felt there were too many injections given, while other women preferred not to use combination vaccines.”
Their concerns about the medical system, meanwhile, involved a general lack of trust for mainstream medicine and anyone involved in the immunization system. They believed that interactions with doctors today differ significantly from the way it was when they were children.
“They did not like feeling pressured by health care providers to vaccinate their kid,” Ms. Mendel said. “If they thought the provider was providing a somewhat authoritative or paternalistic stance with their recommendation, some of these women really shied from that and were dissuaded by that.”
What messages work?
The researchers then tested several messaging approaches with the women that included videos and printouts about vaccine safety, herd immunity, and how vaccines work. The materials received high ratings for being informative, coalescing around 4 on a Likert scale of 1-5, but “in terms of really swaying the needle on confidence, it was barely middle ground,” Ms. Mendel said, referring to scores ranging from 3.1 to 3.4.
“Despite someone thinking something was informative, it doesn’t necessarily change their attitudes or perceptions,” she said.
What the women liked about the materials were clear messaging with a respectful tone that was not patronizing, as well as statistics.
“They wanted information on both the pros and cons, the risks as well as the benefits,” Ms. Mendel said. “They also wanted to believe the information they were interacting with was coming from a reliable source,” although she added that “what we may consider a reliable source may not necessarily be what they consider a reliable source.”
Ultimately, no single message or approach worked well for all the mothers, but they all wanted “balanced messages,” although it wasn’t clear if giving more attention to possible risks would positively influence their beliefs about immunization.
“It’s clear that many sources really shape these views and perceptions around vaccines and immunization for these women,” Ms. Mendel said. “It’s really clear that these women are doing the best they can, or believe they can, to make the best health and wellness decisions for their children. However, as health communicators, I think there remains a lot of opportunities for us to help them do a better job.”
The researchers reported no disclosures and did not report external funding sources.
ATLANTA – Before clinicians can learn new and effective strategies on addressing vaccine hesitancy in their practices, they need to understand both the “forest” and the “trees.” That is, it helps to understand the big picture in terms of national trends, and it’s equally important to understand the motivations and psychology of parents who refuse or remain hesitant about vaccines.
Paula Frew, PhD, MPH, of Emory University in Atlanta, pointed out that vaccination coverage of children under 3 years old in the United States remains consistently high. An estimated 93% of children have received at least three doses of the polio vaccine, 92% have received at least one dose of the MMR vaccine, 92% have received at least three doses of the hepatitis B vaccine, and 91% have received at least one dose of the varicella vaccine.
In fact, less than 1% of parents selectively or completely refuse all vaccines – but an estimated 13%-22% of parents intentionally delay vaccines, Dr. Frew said at a conference sponsored by the Centers for Disease Control and Prevention..
She described findings from a study she and colleagues conducted to assess the influence of vaccination decisions among parents of children under age 7 years. They categorized the parents as nonhesitant acceptors of vaccines, hesitant acceptors, delayers, or refusers. Surveys of 2,603 parents in 2012 and 2,518 parents in 2014 revealed that parents overwhelmingly cite their health care provider as their most trusted source of information on vaccines, including 99% of acceptors and 71% of refusers. Among hesitant acceptors, 49% of parents in 2012 and 48% of parents in 2014 said their doctor positively influenced their vaccination decision.
Qualitative findings from focus groups
Still, hesitancy is common enough that qualitative research is seeking to understand parents’ vaccine concerns. One such study involved focus groups with vaccine-hesitant mothers because mothers or other female guardians are the caregivers most often involved in their children’s health care decisions, according to Judith Mendel, MPH, of the U.S. Department of Health and Human Services.
Ms. Mendel’s study aimed to understand what drives vaccine-related confidence, how to overcome hesitancy over vaccines, and what messaging approaches might work most effectively. She and her colleagues recruited 61 women who participated in one of four groups in the Philadelphia area or one of four in the San Francisco area during April and May 2016. The women all were responsible for the health decisions of at least one child age 5 years or younger and had previously delayed or declined a recommended vaccine for their child.
Each group included six to nine women and involved a 2-hour semistructured discussion about health concerns; what vaccine confidence is; the mothers’ knowledge, attitudes, and beliefs about vaccines and immunization; and feedback on videos and info-graphics designed to educate others about immunization. The focus groups defined having confidence about vaccines as feeling trust, feeling good about a decision, having many years of research or practice, and being informed and knowledgeable.
“Three themes bubbled up together from the groups,” Ms. Mendel said. “Women had concerns about vaccine ingredients and their effects on physiology, about the recommended schedule, and about the medical system.”
Their concerns about vaccine ingredients and physiology would be familiar to pediatric providers:
• A persistent belief that autism is caused by vaccines.
• Concerns about vaccines made from weakened pathogens.
• Belief that vaccines replace a function that the body is equipped to handle on its own.
• Fears about short-term and long-term side effects.
• Little tolerance for established minor reactions to vaccines.
The mothers were accepting of the vaccines that had been on the schedule when they were children, such as polio, but they did not understand why vaccination starts so young and preferred “alternative” or catch-up schedules.
“They believed that when they were younger, the schedule started later,” Ms. Mendel said. “Some women felt there were too many injections given, while other women preferred not to use combination vaccines.”
Their concerns about the medical system, meanwhile, involved a general lack of trust for mainstream medicine and anyone involved in the immunization system. They believed that interactions with doctors today differ significantly from the way it was when they were children.
“They did not like feeling pressured by health care providers to vaccinate their kid,” Ms. Mendel said. “If they thought the provider was providing a somewhat authoritative or paternalistic stance with their recommendation, some of these women really shied from that and were dissuaded by that.”
What messages work?
The researchers then tested several messaging approaches with the women that included videos and printouts about vaccine safety, herd immunity, and how vaccines work. The materials received high ratings for being informative, coalescing around 4 on a Likert scale of 1-5, but “in terms of really swaying the needle on confidence, it was barely middle ground,” Ms. Mendel said, referring to scores ranging from 3.1 to 3.4.
“Despite someone thinking something was informative, it doesn’t necessarily change their attitudes or perceptions,” she said.
What the women liked about the materials were clear messaging with a respectful tone that was not patronizing, as well as statistics.
“They wanted information on both the pros and cons, the risks as well as the benefits,” Ms. Mendel said. “They also wanted to believe the information they were interacting with was coming from a reliable source,” although she added that “what we may consider a reliable source may not necessarily be what they consider a reliable source.”
Ultimately, no single message or approach worked well for all the mothers, but they all wanted “balanced messages,” although it wasn’t clear if giving more attention to possible risks would positively influence their beliefs about immunization.
“It’s clear that many sources really shape these views and perceptions around vaccines and immunization for these women,” Ms. Mendel said. “It’s really clear that these women are doing the best they can, or believe they can, to make the best health and wellness decisions for their children. However, as health communicators, I think there remains a lot of opportunities for us to help them do a better job.”
The researchers reported no disclosures and did not report external funding sources.
ATLANTA – Before clinicians can learn new and effective strategies on addressing vaccine hesitancy in their practices, they need to understand both the “forest” and the “trees.” That is, it helps to understand the big picture in terms of national trends, and it’s equally important to understand the motivations and psychology of parents who refuse or remain hesitant about vaccines.
Paula Frew, PhD, MPH, of Emory University in Atlanta, pointed out that vaccination coverage of children under 3 years old in the United States remains consistently high. An estimated 93% of children have received at least three doses of the polio vaccine, 92% have received at least one dose of the MMR vaccine, 92% have received at least three doses of the hepatitis B vaccine, and 91% have received at least one dose of the varicella vaccine.
In fact, less than 1% of parents selectively or completely refuse all vaccines – but an estimated 13%-22% of parents intentionally delay vaccines, Dr. Frew said at a conference sponsored by the Centers for Disease Control and Prevention..
She described findings from a study she and colleagues conducted to assess the influence of vaccination decisions among parents of children under age 7 years. They categorized the parents as nonhesitant acceptors of vaccines, hesitant acceptors, delayers, or refusers. Surveys of 2,603 parents in 2012 and 2,518 parents in 2014 revealed that parents overwhelmingly cite their health care provider as their most trusted source of information on vaccines, including 99% of acceptors and 71% of refusers. Among hesitant acceptors, 49% of parents in 2012 and 48% of parents in 2014 said their doctor positively influenced their vaccination decision.
Qualitative findings from focus groups
Still, hesitancy is common enough that qualitative research is seeking to understand parents’ vaccine concerns. One such study involved focus groups with vaccine-hesitant mothers because mothers or other female guardians are the caregivers most often involved in their children’s health care decisions, according to Judith Mendel, MPH, of the U.S. Department of Health and Human Services.
Ms. Mendel’s study aimed to understand what drives vaccine-related confidence, how to overcome hesitancy over vaccines, and what messaging approaches might work most effectively. She and her colleagues recruited 61 women who participated in one of four groups in the Philadelphia area or one of four in the San Francisco area during April and May 2016. The women all were responsible for the health decisions of at least one child age 5 years or younger and had previously delayed or declined a recommended vaccine for their child.
Each group included six to nine women and involved a 2-hour semistructured discussion about health concerns; what vaccine confidence is; the mothers’ knowledge, attitudes, and beliefs about vaccines and immunization; and feedback on videos and info-graphics designed to educate others about immunization. The focus groups defined having confidence about vaccines as feeling trust, feeling good about a decision, having many years of research or practice, and being informed and knowledgeable.
“Three themes bubbled up together from the groups,” Ms. Mendel said. “Women had concerns about vaccine ingredients and their effects on physiology, about the recommended schedule, and about the medical system.”
Their concerns about vaccine ingredients and physiology would be familiar to pediatric providers:
• A persistent belief that autism is caused by vaccines.
• Concerns about vaccines made from weakened pathogens.
• Belief that vaccines replace a function that the body is equipped to handle on its own.
• Fears about short-term and long-term side effects.
• Little tolerance for established minor reactions to vaccines.
The mothers were accepting of the vaccines that had been on the schedule when they were children, such as polio, but they did not understand why vaccination starts so young and preferred “alternative” or catch-up schedules.
“They believed that when they were younger, the schedule started later,” Ms. Mendel said. “Some women felt there were too many injections given, while other women preferred not to use combination vaccines.”
Their concerns about the medical system, meanwhile, involved a general lack of trust for mainstream medicine and anyone involved in the immunization system. They believed that interactions with doctors today differ significantly from the way it was when they were children.
“They did not like feeling pressured by health care providers to vaccinate their kid,” Ms. Mendel said. “If they thought the provider was providing a somewhat authoritative or paternalistic stance with their recommendation, some of these women really shied from that and were dissuaded by that.”
What messages work?
The researchers then tested several messaging approaches with the women that included videos and printouts about vaccine safety, herd immunity, and how vaccines work. The materials received high ratings for being informative, coalescing around 4 on a Likert scale of 1-5, but “in terms of really swaying the needle on confidence, it was barely middle ground,” Ms. Mendel said, referring to scores ranging from 3.1 to 3.4.
“Despite someone thinking something was informative, it doesn’t necessarily change their attitudes or perceptions,” she said.
What the women liked about the materials were clear messaging with a respectful tone that was not patronizing, as well as statistics.
“They wanted information on both the pros and cons, the risks as well as the benefits,” Ms. Mendel said. “They also wanted to believe the information they were interacting with was coming from a reliable source,” although she added that “what we may consider a reliable source may not necessarily be what they consider a reliable source.”
Ultimately, no single message or approach worked well for all the mothers, but they all wanted “balanced messages,” although it wasn’t clear if giving more attention to possible risks would positively influence their beliefs about immunization.
“It’s clear that many sources really shape these views and perceptions around vaccines and immunization for these women,” Ms. Mendel said. “It’s really clear that these women are doing the best they can, or believe they can, to make the best health and wellness decisions for their children. However, as health communicators, I think there remains a lot of opportunities for us to help them do a better job.”
The researchers reported no disclosures and did not report external funding sources.
Targeted interventions aid in HPV vaccination uptake
ATLANTA – Holly Groom, MPH, of the Center for Health Research at Kaiser Permanente Northwest, described the intervention to improve HPV vaccination rates within the Kaiser Permanente NW health care system involving two hospitals and 31 medical offices, which serves 44,000 adolescents aged 11-17 years. About a quarter of patients reside in Washington, with the remainder in Oregon.
In addition to two in-person provider education and feedback sessions, the intervention included quarterly vaccine coverage, missed vaccination opportunity assessment reports, and a mailed parent survey. The staff education sessions covered six different cancers caused by HPV – cervical, anal, oropharyngeal, penile, vaginal, and vulvar – and their annual incidence, such as an estimated 10,000 oropharyngeal cancer cases in males and more than 11,000 cervical cancer cases in females each year.
One of the tip sheets distributed during provider and staff education offered specific language that providers could use to recommend the vaccine to parents and educate them about what HPV disease is and what cancers it can cause. For parents who are confused or concerned about why the vaccine is recommended at ages 11-12 years, for example, providers can respond, “We’re vaccinating today so your child will have the best protection possible long before the start of any kind of sexual activity. We vaccinate people well before they are exposed to an infection, as is the case with measles and the other recommended childhood vaccines.”
For those providers uneasy about mentioning sexual activity, Ms. Groom said, they can stick with telling parents the vaccine should be administered “long before the risk of infection” without mentioning the mechanism of infection.
Ms. Groom provided three other recommended statements as well:
• “I strongly believe in the importance of this cancer-preventing vaccine.”
• “I have given HPV vaccine to my son/daughter (or grandchild/niece/nephew/friend’s children).”
• “Experts, such as the American Academy of Pediatrics, cancer doctors, and the Centers for Disease Control and Prevention, also agree that getting the HPV vaccine is very important for your child.”
Feedback from the training sessions was “overwhelmingly positive,” with 87% of the respondents stating that they planned to implement the strategies and tools discussed and an additional 12% said they were already using those strategies and tools.
The parental survey, although it had only a 12% response rate, initially revealed that just over a third (36%) of parents weren’t sure if they were going to vaccinate their child when they went in for a well visit, but more than 90% of these parents did vaccinate their children.
Ms. Groom reported no disclosures. No external funding was reported.
Communication strategies to improve HPV immunization
Several communication strategies have been developed by the Centers for Disease Control and Prevention to help providers overcome barriers to improving HPV immunization coverage, Yvonne Garcia said at the National Immunization Conference.
Among providers’ barriers are hesitancy to make a recommendation for the HPV vaccine, and the need to understand the burden of the disease and the need for the vaccine, said Ms. Garcia, a health communications specialist for the CDC.
“Also, they overestimate parents’ concerns about the vaccine when what we have learned from parents is that they value the HPV vaccine, but they’re not hearing their child’s doctor recommend it,” she said.
Overcoming these barriers requires patient outreach and awareness of HPV coverage rates at the city and state levels, as well as their individual and practice rates. Providers should bundle their recommendation with the other vaccines recommended by the CDC at the ages of 11 and 12 years: “Your child is due for three vaccines today that offer protection against meningitis, HPV cancers, and whooping cough,” is one example of language to use, Ms. Garcia said.
“Effective patient outreach for HPV vaccination includes the reminder/recall system, scheduling remaining doses at the time of receiving the first doses, and creating parental expectation that HPV vaccination is a very normal part of the immunization process, and that it occurs at ages 11 and 12,” she said.
She also reviewed the barriers among parents for HPV vaccination that providers can address. To respond to parents’ lack of knowledge about the vaccine or the need for it, providers “need to stress that it’s needed for cancer prevention,” Ms. Garcia said.
Providers also can reassure parents with concerns about safety and side effects that extensive safety research exists regarding HPV immunization from the past 10 years.
For those worried that HPV vaccination gives “permission for sexual activity” or that kids are too young, providers can reassure parents that the shot is not linked with increased sexual activity, and that it’s recommended at ages 11 and 12 years because the vaccine induces a better immune response at those ages than later on, she said.
Ms. Garcia reported no disclosures. No external funding was reported.
This article was updated Dec. 2, 2016.
ATLANTA – Holly Groom, MPH, of the Center for Health Research at Kaiser Permanente Northwest, described the intervention to improve HPV vaccination rates within the Kaiser Permanente NW health care system involving two hospitals and 31 medical offices, which serves 44,000 adolescents aged 11-17 years. About a quarter of patients reside in Washington, with the remainder in Oregon.
In addition to two in-person provider education and feedback sessions, the intervention included quarterly vaccine coverage, missed vaccination opportunity assessment reports, and a mailed parent survey. The staff education sessions covered six different cancers caused by HPV – cervical, anal, oropharyngeal, penile, vaginal, and vulvar – and their annual incidence, such as an estimated 10,000 oropharyngeal cancer cases in males and more than 11,000 cervical cancer cases in females each year.
One of the tip sheets distributed during provider and staff education offered specific language that providers could use to recommend the vaccine to parents and educate them about what HPV disease is and what cancers it can cause. For parents who are confused or concerned about why the vaccine is recommended at ages 11-12 years, for example, providers can respond, “We’re vaccinating today so your child will have the best protection possible long before the start of any kind of sexual activity. We vaccinate people well before they are exposed to an infection, as is the case with measles and the other recommended childhood vaccines.”
For those providers uneasy about mentioning sexual activity, Ms. Groom said, they can stick with telling parents the vaccine should be administered “long before the risk of infection” without mentioning the mechanism of infection.
Ms. Groom provided three other recommended statements as well:
• “I strongly believe in the importance of this cancer-preventing vaccine.”
• “I have given HPV vaccine to my son/daughter (or grandchild/niece/nephew/friend’s children).”
• “Experts, such as the American Academy of Pediatrics, cancer doctors, and the Centers for Disease Control and Prevention, also agree that getting the HPV vaccine is very important for your child.”
Feedback from the training sessions was “overwhelmingly positive,” with 87% of the respondents stating that they planned to implement the strategies and tools discussed and an additional 12% said they were already using those strategies and tools.
The parental survey, although it had only a 12% response rate, initially revealed that just over a third (36%) of parents weren’t sure if they were going to vaccinate their child when they went in for a well visit, but more than 90% of these parents did vaccinate their children.
Ms. Groom reported no disclosures. No external funding was reported.
Communication strategies to improve HPV immunization
Several communication strategies have been developed by the Centers for Disease Control and Prevention to help providers overcome barriers to improving HPV immunization coverage, Yvonne Garcia said at the National Immunization Conference.
Among providers’ barriers are hesitancy to make a recommendation for the HPV vaccine, and the need to understand the burden of the disease and the need for the vaccine, said Ms. Garcia, a health communications specialist for the CDC.
“Also, they overestimate parents’ concerns about the vaccine when what we have learned from parents is that they value the HPV vaccine, but they’re not hearing their child’s doctor recommend it,” she said.
Overcoming these barriers requires patient outreach and awareness of HPV coverage rates at the city and state levels, as well as their individual and practice rates. Providers should bundle their recommendation with the other vaccines recommended by the CDC at the ages of 11 and 12 years: “Your child is due for three vaccines today that offer protection against meningitis, HPV cancers, and whooping cough,” is one example of language to use, Ms. Garcia said.
“Effective patient outreach for HPV vaccination includes the reminder/recall system, scheduling remaining doses at the time of receiving the first doses, and creating parental expectation that HPV vaccination is a very normal part of the immunization process, and that it occurs at ages 11 and 12,” she said.
She also reviewed the barriers among parents for HPV vaccination that providers can address. To respond to parents’ lack of knowledge about the vaccine or the need for it, providers “need to stress that it’s needed for cancer prevention,” Ms. Garcia said.
Providers also can reassure parents with concerns about safety and side effects that extensive safety research exists regarding HPV immunization from the past 10 years.
For those worried that HPV vaccination gives “permission for sexual activity” or that kids are too young, providers can reassure parents that the shot is not linked with increased sexual activity, and that it’s recommended at ages 11 and 12 years because the vaccine induces a better immune response at those ages than later on, she said.
Ms. Garcia reported no disclosures. No external funding was reported.
This article was updated Dec. 2, 2016.
ATLANTA – Holly Groom, MPH, of the Center for Health Research at Kaiser Permanente Northwest, described the intervention to improve HPV vaccination rates within the Kaiser Permanente NW health care system involving two hospitals and 31 medical offices, which serves 44,000 adolescents aged 11-17 years. About a quarter of patients reside in Washington, with the remainder in Oregon.
In addition to two in-person provider education and feedback sessions, the intervention included quarterly vaccine coverage, missed vaccination opportunity assessment reports, and a mailed parent survey. The staff education sessions covered six different cancers caused by HPV – cervical, anal, oropharyngeal, penile, vaginal, and vulvar – and their annual incidence, such as an estimated 10,000 oropharyngeal cancer cases in males and more than 11,000 cervical cancer cases in females each year.
One of the tip sheets distributed during provider and staff education offered specific language that providers could use to recommend the vaccine to parents and educate them about what HPV disease is and what cancers it can cause. For parents who are confused or concerned about why the vaccine is recommended at ages 11-12 years, for example, providers can respond, “We’re vaccinating today so your child will have the best protection possible long before the start of any kind of sexual activity. We vaccinate people well before they are exposed to an infection, as is the case with measles and the other recommended childhood vaccines.”
For those providers uneasy about mentioning sexual activity, Ms. Groom said, they can stick with telling parents the vaccine should be administered “long before the risk of infection” without mentioning the mechanism of infection.
Ms. Groom provided three other recommended statements as well:
• “I strongly believe in the importance of this cancer-preventing vaccine.”
• “I have given HPV vaccine to my son/daughter (or grandchild/niece/nephew/friend’s children).”
• “Experts, such as the American Academy of Pediatrics, cancer doctors, and the Centers for Disease Control and Prevention, also agree that getting the HPV vaccine is very important for your child.”
Feedback from the training sessions was “overwhelmingly positive,” with 87% of the respondents stating that they planned to implement the strategies and tools discussed and an additional 12% said they were already using those strategies and tools.
The parental survey, although it had only a 12% response rate, initially revealed that just over a third (36%) of parents weren’t sure if they were going to vaccinate their child when they went in for a well visit, but more than 90% of these parents did vaccinate their children.
Ms. Groom reported no disclosures. No external funding was reported.
Communication strategies to improve HPV immunization
Several communication strategies have been developed by the Centers for Disease Control and Prevention to help providers overcome barriers to improving HPV immunization coverage, Yvonne Garcia said at the National Immunization Conference.
Among providers’ barriers are hesitancy to make a recommendation for the HPV vaccine, and the need to understand the burden of the disease and the need for the vaccine, said Ms. Garcia, a health communications specialist for the CDC.
“Also, they overestimate parents’ concerns about the vaccine when what we have learned from parents is that they value the HPV vaccine, but they’re not hearing their child’s doctor recommend it,” she said.
Overcoming these barriers requires patient outreach and awareness of HPV coverage rates at the city and state levels, as well as their individual and practice rates. Providers should bundle their recommendation with the other vaccines recommended by the CDC at the ages of 11 and 12 years: “Your child is due for three vaccines today that offer protection against meningitis, HPV cancers, and whooping cough,” is one example of language to use, Ms. Garcia said.
“Effective patient outreach for HPV vaccination includes the reminder/recall system, scheduling remaining doses at the time of receiving the first doses, and creating parental expectation that HPV vaccination is a very normal part of the immunization process, and that it occurs at ages 11 and 12,” she said.
She also reviewed the barriers among parents for HPV vaccination that providers can address. To respond to parents’ lack of knowledge about the vaccine or the need for it, providers “need to stress that it’s needed for cancer prevention,” Ms. Garcia said.
Providers also can reassure parents with concerns about safety and side effects that extensive safety research exists regarding HPV immunization from the past 10 years.
For those worried that HPV vaccination gives “permission for sexual activity” or that kids are too young, providers can reassure parents that the shot is not linked with increased sexual activity, and that it’s recommended at ages 11 and 12 years because the vaccine induces a better immune response at those ages than later on, she said.
Ms. Garcia reported no disclosures. No external funding was reported.
This article was updated Dec. 2, 2016.
AT THE NATIONAL IMMUNIZATION CONFERENCE
Key clinical point: Targeted interventions to improve HPV vaccination can be effective.
Major finding: In one health care system’s intervention, 87% of providers found the tools and strategies for increasing HPV vaccination uptake helpful and worth using.
Data source: A study within the Kaiser Permanente NW health care system involving two hospitals and 31 medical offices, which serves 44,000 adolescents aged 11-17 years.
Disclosures: Dr. Groom reported no disclosures. No external funding was reported.
Prenatal exposure to hydroxychloroquine cuts risk of neonatal cutaneous lupus
WASHINGTON – Prenatal hydroxychloroquine reduces the risk of cutaneous neonatal lupus by 60% among the infants of women with a systemic autoimmune rheumatic disease.
The medication easily passes the placental barrier and confers significant protection to neonates born to women who have anti-Ro and anti-La antibodies, Julie Barsalou, MD, said at the annual meeting of the American College of Rheumatology.
Toll-like receptors 7 and 9 have been implicated in the initiation and maintenance of interface dermatitis, and hydroxychloroquine inhibits these receptors. In mouse studies, the drug has led to improvement of this type of dermatitis. Hydroxychloroquine also works well in treating subacute cutaneous lupus, she said, and because it can travel across the placenta, it could be an effective means of preventing this disorder in at-risk neonates.
To examine any potential benefit, Dr. Barsalou looked at three pediatric lupus databases: the SickKids NLE database from Toronto, the U.S. Research Registry for Neonatal Lupus, and the French Registry for Neonatal Lupus.
These registries include infants born to mothers with anti-Ro and/or anti-La antibodies, and a diagnosis of lupus, dermatomyositis, Sjögren’s syndrome, juvenile idiopathic arthritis, or rheumatic arthritis. No infants with cardiac neonatal lupus were included in the study.
In addition to hydroxychloroquine, Dr. Barsalou examined the use of prenatal azathioprine, nonfluorinated and fluorinated steroids, and intravenous immunoglobulin.
The cohort comprised 545 neonates born to 535 mothers. Among these, 112 developed cNLE. The remaining 433 infants were used as controls.
Mothers of both cases and controls were a mean age of 31 years. Among cases, the most common diagnosis was Sjögren’s syndrome (53%), followed by systemic lupus erythematosus (46%). Among controls, the most common maternal diagnosis was SLE (62%), followed by Sjögren’s (31%).
All mothers of cases were positive for anti-Ro antibodies; 72% were positive for anti-La antibodies. Among mothers of controls, 99% had anti-Ro antibodies and 48% had anti-La antibodies.
Mothers of cases took hydroxychloroquine (17%), fluorinated steroids (6%), and nonfluorinated steroids with or without azathioprine (28%). Mothers of controls took hydroxychloroquine (34%), fluorinated steroids (4%), and nonfluorinated steroids with or without azathioprine (44%),
There were significantly more female than male infants in the case group (65%). The median age at rash onset was 6 weeks.
Dr. Barsalou performed several multivariate analyses on the entire cohort, as well as two subgroup analyses: one on infants who developed the cNLE rash within the first 4 weeks of life and one on only the infants of mothers with SLE.
In the primary analysis, maternal anti-Ro and anti-La antibodies more than doubled the risk of an infant developing cNLE (odds ratio, 2.5). The use of hydroxychloroquine decreased this risk by 60% (OR, 0.4). Being a female infant increased the risk by 70% (OR, 1.7).
In the group of infants with early-onset rash, maternal anti-La antibodies more than tripled the risk (OR, 3.5), while the use of hydroxychloroquine decreased the risk by 80% (OR, 0.2).
Among the infants born to women with SLE, concomitant secondary Sjögren’s syndrome increased the risk of cNLE by more than threefold (OR, 3.5). Anti-La antibodies more than doubled the risk (OR, 2.5), and the use of hydroxychloroquine decreased it by 60% (OR, 0.4).
“This is the first study to address the prevention of cutaneous neonatal lupus,” Dr. Barsalou said. “We found that prenatal exposure to hydroxychloroquine is likely protective.”
She had no financial disclosures.
msullivan@frontlinemedcom.com
On Twitter @alz_gal
WASHINGTON – Prenatal hydroxychloroquine reduces the risk of cutaneous neonatal lupus by 60% among the infants of women with a systemic autoimmune rheumatic disease.
The medication easily passes the placental barrier and confers significant protection to neonates born to women who have anti-Ro and anti-La antibodies, Julie Barsalou, MD, said at the annual meeting of the American College of Rheumatology.
Toll-like receptors 7 and 9 have been implicated in the initiation and maintenance of interface dermatitis, and hydroxychloroquine inhibits these receptors. In mouse studies, the drug has led to improvement of this type of dermatitis. Hydroxychloroquine also works well in treating subacute cutaneous lupus, she said, and because it can travel across the placenta, it could be an effective means of preventing this disorder in at-risk neonates.
To examine any potential benefit, Dr. Barsalou looked at three pediatric lupus databases: the SickKids NLE database from Toronto, the U.S. Research Registry for Neonatal Lupus, and the French Registry for Neonatal Lupus.
These registries include infants born to mothers with anti-Ro and/or anti-La antibodies, and a diagnosis of lupus, dermatomyositis, Sjögren’s syndrome, juvenile idiopathic arthritis, or rheumatic arthritis. No infants with cardiac neonatal lupus were included in the study.
In addition to hydroxychloroquine, Dr. Barsalou examined the use of prenatal azathioprine, nonfluorinated and fluorinated steroids, and intravenous immunoglobulin.
The cohort comprised 545 neonates born to 535 mothers. Among these, 112 developed cNLE. The remaining 433 infants were used as controls.
Mothers of both cases and controls were a mean age of 31 years. Among cases, the most common diagnosis was Sjögren’s syndrome (53%), followed by systemic lupus erythematosus (46%). Among controls, the most common maternal diagnosis was SLE (62%), followed by Sjögren’s (31%).
All mothers of cases were positive for anti-Ro antibodies; 72% were positive for anti-La antibodies. Among mothers of controls, 99% had anti-Ro antibodies and 48% had anti-La antibodies.
Mothers of cases took hydroxychloroquine (17%), fluorinated steroids (6%), and nonfluorinated steroids with or without azathioprine (28%). Mothers of controls took hydroxychloroquine (34%), fluorinated steroids (4%), and nonfluorinated steroids with or without azathioprine (44%),
There were significantly more female than male infants in the case group (65%). The median age at rash onset was 6 weeks.
Dr. Barsalou performed several multivariate analyses on the entire cohort, as well as two subgroup analyses: one on infants who developed the cNLE rash within the first 4 weeks of life and one on only the infants of mothers with SLE.
In the primary analysis, maternal anti-Ro and anti-La antibodies more than doubled the risk of an infant developing cNLE (odds ratio, 2.5). The use of hydroxychloroquine decreased this risk by 60% (OR, 0.4). Being a female infant increased the risk by 70% (OR, 1.7).
In the group of infants with early-onset rash, maternal anti-La antibodies more than tripled the risk (OR, 3.5), while the use of hydroxychloroquine decreased the risk by 80% (OR, 0.2).
Among the infants born to women with SLE, concomitant secondary Sjögren’s syndrome increased the risk of cNLE by more than threefold (OR, 3.5). Anti-La antibodies more than doubled the risk (OR, 2.5), and the use of hydroxychloroquine decreased it by 60% (OR, 0.4).
“This is the first study to address the prevention of cutaneous neonatal lupus,” Dr. Barsalou said. “We found that prenatal exposure to hydroxychloroquine is likely protective.”
She had no financial disclosures.
msullivan@frontlinemedcom.com
On Twitter @alz_gal
WASHINGTON – Prenatal hydroxychloroquine reduces the risk of cutaneous neonatal lupus by 60% among the infants of women with a systemic autoimmune rheumatic disease.
The medication easily passes the placental barrier and confers significant protection to neonates born to women who have anti-Ro and anti-La antibodies, Julie Barsalou, MD, said at the annual meeting of the American College of Rheumatology.
Toll-like receptors 7 and 9 have been implicated in the initiation and maintenance of interface dermatitis, and hydroxychloroquine inhibits these receptors. In mouse studies, the drug has led to improvement of this type of dermatitis. Hydroxychloroquine also works well in treating subacute cutaneous lupus, she said, and because it can travel across the placenta, it could be an effective means of preventing this disorder in at-risk neonates.
To examine any potential benefit, Dr. Barsalou looked at three pediatric lupus databases: the SickKids NLE database from Toronto, the U.S. Research Registry for Neonatal Lupus, and the French Registry for Neonatal Lupus.
These registries include infants born to mothers with anti-Ro and/or anti-La antibodies, and a diagnosis of lupus, dermatomyositis, Sjögren’s syndrome, juvenile idiopathic arthritis, or rheumatic arthritis. No infants with cardiac neonatal lupus were included in the study.
In addition to hydroxychloroquine, Dr. Barsalou examined the use of prenatal azathioprine, nonfluorinated and fluorinated steroids, and intravenous immunoglobulin.
The cohort comprised 545 neonates born to 535 mothers. Among these, 112 developed cNLE. The remaining 433 infants were used as controls.
Mothers of both cases and controls were a mean age of 31 years. Among cases, the most common diagnosis was Sjögren’s syndrome (53%), followed by systemic lupus erythematosus (46%). Among controls, the most common maternal diagnosis was SLE (62%), followed by Sjögren’s (31%).
All mothers of cases were positive for anti-Ro antibodies; 72% were positive for anti-La antibodies. Among mothers of controls, 99% had anti-Ro antibodies and 48% had anti-La antibodies.
Mothers of cases took hydroxychloroquine (17%), fluorinated steroids (6%), and nonfluorinated steroids with or without azathioprine (28%). Mothers of controls took hydroxychloroquine (34%), fluorinated steroids (4%), and nonfluorinated steroids with or without azathioprine (44%),
There were significantly more female than male infants in the case group (65%). The median age at rash onset was 6 weeks.
Dr. Barsalou performed several multivariate analyses on the entire cohort, as well as two subgroup analyses: one on infants who developed the cNLE rash within the first 4 weeks of life and one on only the infants of mothers with SLE.
In the primary analysis, maternal anti-Ro and anti-La antibodies more than doubled the risk of an infant developing cNLE (odds ratio, 2.5). The use of hydroxychloroquine decreased this risk by 60% (OR, 0.4). Being a female infant increased the risk by 70% (OR, 1.7).
In the group of infants with early-onset rash, maternal anti-La antibodies more than tripled the risk (OR, 3.5), while the use of hydroxychloroquine decreased the risk by 80% (OR, 0.2).
Among the infants born to women with SLE, concomitant secondary Sjögren’s syndrome increased the risk of cNLE by more than threefold (OR, 3.5). Anti-La antibodies more than doubled the risk (OR, 2.5), and the use of hydroxychloroquine decreased it by 60% (OR, 0.4).
“This is the first study to address the prevention of cutaneous neonatal lupus,” Dr. Barsalou said. “We found that prenatal exposure to hydroxychloroquine is likely protective.”
She had no financial disclosures.
msullivan@frontlinemedcom.com
On Twitter @alz_gal
AT THE ACR ANNUAL MEETING
Key clinical point:
Major finding: The drug was associated with a 60% decreased risk of developing the disorder.
Data source: The case-control study involved 545 infants.
Disclosures: Dr. Barsalou had no financial disclosures.
Autism risk not increased by maternal influenza infection during pregnancy
Maternal influenza infection during pregnancy does not increase the risk for autism spectrum disorder (ASD) in children, according to Ousseny Zerbo, PhD, and associates.
In a study of 196,929 mother-child pairs (the children were born at Kaiser Permanente Northern California between Jan. 1, 2000, and Dec. 31, 2010), 1.6% of the children were diagnosed with ASD. Influenza was diagnosed in 0.7% of mothers during their pregnancy, and 23% received an influenza vaccination during pregnancy.
Overall, maternal influenza vaccination did not effect likelihood of ASD diagnosis, with 1.7% of children in this group receiving an ASD diagnosis. A small association between ASD diagnosis and maternal influenza vaccination, however, was seen in the first trimester of pregnancy, with an adjusted hazard ratio of 1.2, translating to a potential extra 4 cases of autism per 1,000 births. But further analysis suggested that this could be caused by bias and chance, and “the association was insignificant after statistical correction for multiple comparisons,” the investigators said.
“While we do not advocate changes in vaccine policy or practice, we believe that additional studies are warranted to further evaluate any potential associations between first-trimester maternal influenza vaccination and autism,” the investigators concluded.
Find the full study in JAMA Pediatrics (doi: 10.1001/jamapediatrics.2016.3609).
Maternal influenza infection during pregnancy does not increase the risk for autism spectrum disorder (ASD) in children, according to Ousseny Zerbo, PhD, and associates.
In a study of 196,929 mother-child pairs (the children were born at Kaiser Permanente Northern California between Jan. 1, 2000, and Dec. 31, 2010), 1.6% of the children were diagnosed with ASD. Influenza was diagnosed in 0.7% of mothers during their pregnancy, and 23% received an influenza vaccination during pregnancy.
Overall, maternal influenza vaccination did not effect likelihood of ASD diagnosis, with 1.7% of children in this group receiving an ASD diagnosis. A small association between ASD diagnosis and maternal influenza vaccination, however, was seen in the first trimester of pregnancy, with an adjusted hazard ratio of 1.2, translating to a potential extra 4 cases of autism per 1,000 births. But further analysis suggested that this could be caused by bias and chance, and “the association was insignificant after statistical correction for multiple comparisons,” the investigators said.
“While we do not advocate changes in vaccine policy or practice, we believe that additional studies are warranted to further evaluate any potential associations between first-trimester maternal influenza vaccination and autism,” the investigators concluded.
Find the full study in JAMA Pediatrics (doi: 10.1001/jamapediatrics.2016.3609).
Maternal influenza infection during pregnancy does not increase the risk for autism spectrum disorder (ASD) in children, according to Ousseny Zerbo, PhD, and associates.
In a study of 196,929 mother-child pairs (the children were born at Kaiser Permanente Northern California between Jan. 1, 2000, and Dec. 31, 2010), 1.6% of the children were diagnosed with ASD. Influenza was diagnosed in 0.7% of mothers during their pregnancy, and 23% received an influenza vaccination during pregnancy.
Overall, maternal influenza vaccination did not effect likelihood of ASD diagnosis, with 1.7% of children in this group receiving an ASD diagnosis. A small association between ASD diagnosis and maternal influenza vaccination, however, was seen in the first trimester of pregnancy, with an adjusted hazard ratio of 1.2, translating to a potential extra 4 cases of autism per 1,000 births. But further analysis suggested that this could be caused by bias and chance, and “the association was insignificant after statistical correction for multiple comparisons,” the investigators said.
“While we do not advocate changes in vaccine policy or practice, we believe that additional studies are warranted to further evaluate any potential associations between first-trimester maternal influenza vaccination and autism,” the investigators concluded.
Find the full study in JAMA Pediatrics (doi: 10.1001/jamapediatrics.2016.3609).
FROM JAMA PEDIATRICS
Cultural approach to vaccine hesitancy essential for ethnic communities
ATLANTA – Research into vaccine hesitancy in the United States tends to focus on overall trends among native-born Americans or immigrants who have mostly assimilated into American culture. But the nation is dotted with tight-knit ethnic communities which have immigrated to the United States, including refugee communities that retain much of the culture and practices of their home country.
Developing interventions to address vaccine hesitancy in these communities may require a significantly different approach than it would in fully assimilated groups, with a need to start by learning about the culture, fears, values and priorities of that particular community.
A 2000 study had shown Somali parents were generally supportive of immunization, but that perception had changed by summer of 2008, explained co-presenter Lynn Bahta, RN, PHN, an immunization clinical consultant at the Minnesota Department of Health Immunization Program. A local TV station ran a story about Somali parents’ concern that a disproportionately higher number of Somali children were in early childhood special education programs for autism.
“In the middle of the report, a parent stated, ‘It’s the vaccines,’ ” Ms. Bahta said. Because they did not have a word for autism in Somali, parents’ online searches led them to groups promoting the misconception that the MMR vaccine and autism were linked. Clinicians in Minnesota began to report Somali parents’ refusal to get their children’s 12-month vaccines. Then a 2011 measles outbreak led the Minnesota Department of Health to look at MMR vaccination rates among local Somalis.
Somalis had a higher rate of MMR coverage in 24-month-old children than did non-Somalis in 2004 – 90%, compared with 84% – according to the Minnesota Immunization Information Connection. But MMR rates among Somali 24-month-olds began dropping in 2005, reaching 82% in 2007 and 63% in 2009.
“The data we got instilled a bit of panic in the immunization team,” Ms. Bahta said. “Parents were still supporting immunizations, but they weren’t getting that MMR.”
Traditional strategies to increase vaccination – distributing travel immunization information, promoting YouTube videos about immunization and autism, using diverse media for information campaigns – failed.
So they joined with the community and family health department, where co-presenter Asli Ashkir, RN, MPH, is a senior nurse consultant in the Children & Youth with Special Health Needs program. They also hired Somali staff and began to improve their cultural knowledge and competence.
With Somalis, social life revolves around family ties, the community, and faith, explained Ms. Ashkir, a Somali woman herself. Somali culture is based on oral tradition, one that shares information among themselves and provides unsolicited advice to one another, and they persuade each other easily. But issues of health, life, and death are in the hands of Allah only, she said.
“There is a time you will die, whether you are vaccinated or not,” Ms. Ashkir explained. “That doesn’t mean we don’t practice preventive service or health promotion – we do – but at the back of our head, when our time is over, you’re going to go. These are the people we are working with.”
Two other potential obstacles involve Somali beliefs about sin and mental illness.
“We believe if someone is ill, their sins will be cleansed,” she said, explaining why Somalis with minor health problems don’t seek health care. “Parents with kids who have autism keep kids in their apartment until they are 8 years old because mental illness has a negative stigma.”
The Minnesota Department of Health conducted a study on the experience of having a child with autism in the Somali community and discovered four key themes. First, the parents greatly feared autism: Every Somali interviewed said they did not get the MMR because they wanted to avoid autism. Second, parents lacked information about normal child development, autism, and the diseases that vaccines prevent.
“We were expecting parents to identify developmental delays, but parents look not at the development but the growth, at the physical size of the child,” Ms. Ashkir said. And when they learned that the MMR prevented measles – the No. 3 killer of children in Somalia – parents often wanted the shot immediately.
The other two discoveries were that it was impossible to talk about immunization issues in isolation – they were too intricately entwined with discussions about autism – and that Somalis wanted to hear information from respected community sources.
These findings were applied in a pilot program that aimed to improve parents’ knowledge about child growth and development, autism, and vaccine-preventable diseases. Six mothers attended the training program, and tracking their contacts revealed that the information had traveled to 82 other family, friends, and neighbors within the first 3 months. All the women found the program “very helpful” with no negative responses.
The success of this program led to a more comprehensive approach that included training and outreach, engaging the community, disease mitigation and control, and creating and expanding partnerships with organizations such as the state American Academy of Pediatrics chapter, the Somali American Parent Association, the Minnesota Medical Association, and Parents in Community Action.
Training included all-Somali speakers with messages from spiritual leaders and parents of children with autism. Community outreach involved one-on-one conversations among Somalis at information tables in places such as malls, mosques, community centers, and libraries.
“Among this group, there are four parents who have children with autism,” Ms. Ashkir said. “Two of these parents are very, very vocal and talk about their children who have autism, and that they did not give them the MMR. They tell people ‘You have wrong information.’ ”
As of March 2016, the decline in MMR vaccination rates among Somalis had started to flatten. The annual drop of 5%-7% a year in MMR rates became 0.89% last year, which the Minnesota Department of Health finds encouraging.
“Our initial efforts, which included a typical repertoire of public health interventions, were ineffective, so we had to go back and dig deep to understand the core concerns,” Ms. Bahta said. “Our information had to address the core concerns of the community, not what we assumed to be the issue.”
Credibility came from the cultural relevancy of the message, and the fact that those providing the message were parents who had vaccinated their children, she said.
“Each cultural group needs unique approaches, and this is certainly true in this situation – to understand the unique perspective of the community and develop an effective approach required bringing in culturally competent staff and engaging the community,” Ms. Bahta said.
ATLANTA – Research into vaccine hesitancy in the United States tends to focus on overall trends among native-born Americans or immigrants who have mostly assimilated into American culture. But the nation is dotted with tight-knit ethnic communities which have immigrated to the United States, including refugee communities that retain much of the culture and practices of their home country.
Developing interventions to address vaccine hesitancy in these communities may require a significantly different approach than it would in fully assimilated groups, with a need to start by learning about the culture, fears, values and priorities of that particular community.
A 2000 study had shown Somali parents were generally supportive of immunization, but that perception had changed by summer of 2008, explained co-presenter Lynn Bahta, RN, PHN, an immunization clinical consultant at the Minnesota Department of Health Immunization Program. A local TV station ran a story about Somali parents’ concern that a disproportionately higher number of Somali children were in early childhood special education programs for autism.
“In the middle of the report, a parent stated, ‘It’s the vaccines,’ ” Ms. Bahta said. Because they did not have a word for autism in Somali, parents’ online searches led them to groups promoting the misconception that the MMR vaccine and autism were linked. Clinicians in Minnesota began to report Somali parents’ refusal to get their children’s 12-month vaccines. Then a 2011 measles outbreak led the Minnesota Department of Health to look at MMR vaccination rates among local Somalis.
Somalis had a higher rate of MMR coverage in 24-month-old children than did non-Somalis in 2004 – 90%, compared with 84% – according to the Minnesota Immunization Information Connection. But MMR rates among Somali 24-month-olds began dropping in 2005, reaching 82% in 2007 and 63% in 2009.
“The data we got instilled a bit of panic in the immunization team,” Ms. Bahta said. “Parents were still supporting immunizations, but they weren’t getting that MMR.”
Traditional strategies to increase vaccination – distributing travel immunization information, promoting YouTube videos about immunization and autism, using diverse media for information campaigns – failed.
So they joined with the community and family health department, where co-presenter Asli Ashkir, RN, MPH, is a senior nurse consultant in the Children & Youth with Special Health Needs program. They also hired Somali staff and began to improve their cultural knowledge and competence.
With Somalis, social life revolves around family ties, the community, and faith, explained Ms. Ashkir, a Somali woman herself. Somali culture is based on oral tradition, one that shares information among themselves and provides unsolicited advice to one another, and they persuade each other easily. But issues of health, life, and death are in the hands of Allah only, she said.
“There is a time you will die, whether you are vaccinated or not,” Ms. Ashkir explained. “That doesn’t mean we don’t practice preventive service or health promotion – we do – but at the back of our head, when our time is over, you’re going to go. These are the people we are working with.”
Two other potential obstacles involve Somali beliefs about sin and mental illness.
“We believe if someone is ill, their sins will be cleansed,” she said, explaining why Somalis with minor health problems don’t seek health care. “Parents with kids who have autism keep kids in their apartment until they are 8 years old because mental illness has a negative stigma.”
The Minnesota Department of Health conducted a study on the experience of having a child with autism in the Somali community and discovered four key themes. First, the parents greatly feared autism: Every Somali interviewed said they did not get the MMR because they wanted to avoid autism. Second, parents lacked information about normal child development, autism, and the diseases that vaccines prevent.
“We were expecting parents to identify developmental delays, but parents look not at the development but the growth, at the physical size of the child,” Ms. Ashkir said. And when they learned that the MMR prevented measles – the No. 3 killer of children in Somalia – parents often wanted the shot immediately.
The other two discoveries were that it was impossible to talk about immunization issues in isolation – they were too intricately entwined with discussions about autism – and that Somalis wanted to hear information from respected community sources.
These findings were applied in a pilot program that aimed to improve parents’ knowledge about child growth and development, autism, and vaccine-preventable diseases. Six mothers attended the training program, and tracking their contacts revealed that the information had traveled to 82 other family, friends, and neighbors within the first 3 months. All the women found the program “very helpful” with no negative responses.
The success of this program led to a more comprehensive approach that included training and outreach, engaging the community, disease mitigation and control, and creating and expanding partnerships with organizations such as the state American Academy of Pediatrics chapter, the Somali American Parent Association, the Minnesota Medical Association, and Parents in Community Action.
Training included all-Somali speakers with messages from spiritual leaders and parents of children with autism. Community outreach involved one-on-one conversations among Somalis at information tables in places such as malls, mosques, community centers, and libraries.
“Among this group, there are four parents who have children with autism,” Ms. Ashkir said. “Two of these parents are very, very vocal and talk about their children who have autism, and that they did not give them the MMR. They tell people ‘You have wrong information.’ ”
As of March 2016, the decline in MMR vaccination rates among Somalis had started to flatten. The annual drop of 5%-7% a year in MMR rates became 0.89% last year, which the Minnesota Department of Health finds encouraging.
“Our initial efforts, which included a typical repertoire of public health interventions, were ineffective, so we had to go back and dig deep to understand the core concerns,” Ms. Bahta said. “Our information had to address the core concerns of the community, not what we assumed to be the issue.”
Credibility came from the cultural relevancy of the message, and the fact that those providing the message were parents who had vaccinated their children, she said.
“Each cultural group needs unique approaches, and this is certainly true in this situation – to understand the unique perspective of the community and develop an effective approach required bringing in culturally competent staff and engaging the community,” Ms. Bahta said.
ATLANTA – Research into vaccine hesitancy in the United States tends to focus on overall trends among native-born Americans or immigrants who have mostly assimilated into American culture. But the nation is dotted with tight-knit ethnic communities which have immigrated to the United States, including refugee communities that retain much of the culture and practices of their home country.
Developing interventions to address vaccine hesitancy in these communities may require a significantly different approach than it would in fully assimilated groups, with a need to start by learning about the culture, fears, values and priorities of that particular community.
A 2000 study had shown Somali parents were generally supportive of immunization, but that perception had changed by summer of 2008, explained co-presenter Lynn Bahta, RN, PHN, an immunization clinical consultant at the Minnesota Department of Health Immunization Program. A local TV station ran a story about Somali parents’ concern that a disproportionately higher number of Somali children were in early childhood special education programs for autism.
“In the middle of the report, a parent stated, ‘It’s the vaccines,’ ” Ms. Bahta said. Because they did not have a word for autism in Somali, parents’ online searches led them to groups promoting the misconception that the MMR vaccine and autism were linked. Clinicians in Minnesota began to report Somali parents’ refusal to get their children’s 12-month vaccines. Then a 2011 measles outbreak led the Minnesota Department of Health to look at MMR vaccination rates among local Somalis.
Somalis had a higher rate of MMR coverage in 24-month-old children than did non-Somalis in 2004 – 90%, compared with 84% – according to the Minnesota Immunization Information Connection. But MMR rates among Somali 24-month-olds began dropping in 2005, reaching 82% in 2007 and 63% in 2009.
“The data we got instilled a bit of panic in the immunization team,” Ms. Bahta said. “Parents were still supporting immunizations, but they weren’t getting that MMR.”
Traditional strategies to increase vaccination – distributing travel immunization information, promoting YouTube videos about immunization and autism, using diverse media for information campaigns – failed.
So they joined with the community and family health department, where co-presenter Asli Ashkir, RN, MPH, is a senior nurse consultant in the Children & Youth with Special Health Needs program. They also hired Somali staff and began to improve their cultural knowledge and competence.
With Somalis, social life revolves around family ties, the community, and faith, explained Ms. Ashkir, a Somali woman herself. Somali culture is based on oral tradition, one that shares information among themselves and provides unsolicited advice to one another, and they persuade each other easily. But issues of health, life, and death are in the hands of Allah only, she said.
“There is a time you will die, whether you are vaccinated or not,” Ms. Ashkir explained. “That doesn’t mean we don’t practice preventive service or health promotion – we do – but at the back of our head, when our time is over, you’re going to go. These are the people we are working with.”
Two other potential obstacles involve Somali beliefs about sin and mental illness.
“We believe if someone is ill, their sins will be cleansed,” she said, explaining why Somalis with minor health problems don’t seek health care. “Parents with kids who have autism keep kids in their apartment until they are 8 years old because mental illness has a negative stigma.”
The Minnesota Department of Health conducted a study on the experience of having a child with autism in the Somali community and discovered four key themes. First, the parents greatly feared autism: Every Somali interviewed said they did not get the MMR because they wanted to avoid autism. Second, parents lacked information about normal child development, autism, and the diseases that vaccines prevent.
“We were expecting parents to identify developmental delays, but parents look not at the development but the growth, at the physical size of the child,” Ms. Ashkir said. And when they learned that the MMR prevented measles – the No. 3 killer of children in Somalia – parents often wanted the shot immediately.
The other two discoveries were that it was impossible to talk about immunization issues in isolation – they were too intricately entwined with discussions about autism – and that Somalis wanted to hear information from respected community sources.
These findings were applied in a pilot program that aimed to improve parents’ knowledge about child growth and development, autism, and vaccine-preventable diseases. Six mothers attended the training program, and tracking their contacts revealed that the information had traveled to 82 other family, friends, and neighbors within the first 3 months. All the women found the program “very helpful” with no negative responses.
The success of this program led to a more comprehensive approach that included training and outreach, engaging the community, disease mitigation and control, and creating and expanding partnerships with organizations such as the state American Academy of Pediatrics chapter, the Somali American Parent Association, the Minnesota Medical Association, and Parents in Community Action.
Training included all-Somali speakers with messages from spiritual leaders and parents of children with autism. Community outreach involved one-on-one conversations among Somalis at information tables in places such as malls, mosques, community centers, and libraries.
“Among this group, there are four parents who have children with autism,” Ms. Ashkir said. “Two of these parents are very, very vocal and talk about their children who have autism, and that they did not give them the MMR. They tell people ‘You have wrong information.’ ”
As of March 2016, the decline in MMR vaccination rates among Somalis had started to flatten. The annual drop of 5%-7% a year in MMR rates became 0.89% last year, which the Minnesota Department of Health finds encouraging.
“Our initial efforts, which included a typical repertoire of public health interventions, were ineffective, so we had to go back and dig deep to understand the core concerns,” Ms. Bahta said. “Our information had to address the core concerns of the community, not what we assumed to be the issue.”
Credibility came from the cultural relevancy of the message, and the fact that those providing the message were parents who had vaccinated their children, she said.
“Each cultural group needs unique approaches, and this is certainly true in this situation – to understand the unique perspective of the community and develop an effective approach required bringing in culturally competent staff and engaging the community,” Ms. Bahta said.
AT THE NATIONAL IMMUNIZATION CONFERENCE
Key clinical point:
Major finding: The decline in MMR vaccination among Somali children in Minnesota went from a 5%-7% annual drop to a 0.89% drop in 2015.
Data source: The findings are based on a comprehensive training and outreach program developed at the Minnesota Department of Health.
Disclosures: The initiative was funded by the Minnesota Department of Health. Ms. Ashkir and Ms. Bahta reported they had no conflicts to disclose.
HPV vaccination rates tripled with practice’s comprehensive intervention
ATLANTA – A multifaceted comprehensive intervention significantly improved human papillomavirus (HPV) vaccination rates in a Florida pediatric health care group practice.
Alix G. Casler, MD, chief of pediatrics at Orlando Health Physician Associates, described how her practice put into place practices to improve the overall HPV vaccination rate of their clients.
She described the critical components of a vaccination quality improvement project: set specific goals, know your practice’s actual rates, identify areas of weakness and/or opportunity, and then implement effective and sustainable processes for improvement. Their initial goal was to show any improvement at all in the first year and then to meet the highest national rates 2 years later.
“We started by agreeing we would become transparent to one another,” Dr. Casler explained. “This is called peer influence. What we didn’t want to be was the one who deviated from standard practice.”
As they got further along into their initiative, this transparency led physicians to ask others with better rates for help. “It’s not just a motivator in terms of not wanting to be the worse; it’s also a motivator in knowing how to get help,” said Dr. Casler, also at Florida State College of Medicine in Tallahassee and the University of Central Florida in Orlando.
Individual physicians’ rates were first shared privately with that physician, then shared with the department, and then published monthly and eventually only quarterly.
Then they developed the interventions to improve rates: verification and clean-up of their data, physician and staff education, physician incentives, previsit planning, electronic follow-up orders for the second and third doses, reminder calls, manufacturer tools, and clinical summaries.
The physician education program involved first making HPV vaccination a priority even when multiple competing priorities exist at each well visit.
“Our doctors felt, as all doctors feel, that we have 75 things to do and it’s not possible to do them all,” Dr. Casler said. “If we don’t have a fast and dirty way of doing something, it won’t get done.”
Part of prioritizing the vaccine was making physicians aware of how common HPV and HPV diseases were, which many did not realize. Then the training addressed providers’ discomfort about discussing the vaccine. They provided a script that included a clear recommendation for the HPV vaccine – sandwiched between the recommendations for the meningitis and Tdap vaccines – without adding unnecessary extra information unless the parent requested it.
During staff training, her practice found similar obstacles as with the doctors. “They had different competing priorities, they didn’t really know what HPV was, and they didn’t want to talk about sex,” Dr. Casler said.
Following training, they distributed tools such as posters and fact sheets to physicians and developed incentives: competition among each other, a quality bonus structure, and wine. “It’s amazing what will motivate people,” Dr. Casler said with a smile. “Again, this is the real world.”
Daily previsit planning meant documenting on patient lists the priorities for each patient, including the HPV vaccine as well as needs such as flu shots; other vaccines; screening for asthma, depression, and STIs; smoking assessment; diet and exercise counseling; and risk factor assessments.
“That is one of the most valuable interventions and got a tremendous amount of feedback from the staff,” Dr. Casler said. “Any practice can do this for free. I look at every metric that needs to be covered with that patient during that visit.”
Patients then are required to schedule their second and third doses on their way out. “If someone no-shows or doesn’t reschedule, my secretary knows what HPV is and what it does,” Dr. Casler said. “She will call the parents and leave a message, ‘Call me tomorrow to reschedule your appointment... so that your child doesn’t get cancer.”
In evaluating the program, Dr. Casler said the most popular interventions were the physician and staff education programs, scheduling subsequent doses in real time, and using manufacturer-supplied tools such as magnets and cling posters. Staff involvement turned out to be a critical resource in the overall intervention as well.
As a result of the program begun in August 2013, the practice’s rates of girls and boys receiving one dose of the HPV vaccine increased to 65% and 57%, respectively, by the end of 2014. Further, 43% of girls and 30% of boys received all three doses. By June 2016, 75% of girls and 72% of boys were receiving their first dose of HPV vaccine, and 55% of girls and 47% of boys were receiving all three doses.
Dr. Casler reported previous consulting and speaking for Merck and Sanofi Pasteur. No external funding was reported.
ATLANTA – A multifaceted comprehensive intervention significantly improved human papillomavirus (HPV) vaccination rates in a Florida pediatric health care group practice.
Alix G. Casler, MD, chief of pediatrics at Orlando Health Physician Associates, described how her practice put into place practices to improve the overall HPV vaccination rate of their clients.
She described the critical components of a vaccination quality improvement project: set specific goals, know your practice’s actual rates, identify areas of weakness and/or opportunity, and then implement effective and sustainable processes for improvement. Their initial goal was to show any improvement at all in the first year and then to meet the highest national rates 2 years later.
“We started by agreeing we would become transparent to one another,” Dr. Casler explained. “This is called peer influence. What we didn’t want to be was the one who deviated from standard practice.”
As they got further along into their initiative, this transparency led physicians to ask others with better rates for help. “It’s not just a motivator in terms of not wanting to be the worse; it’s also a motivator in knowing how to get help,” said Dr. Casler, also at Florida State College of Medicine in Tallahassee and the University of Central Florida in Orlando.
Individual physicians’ rates were first shared privately with that physician, then shared with the department, and then published monthly and eventually only quarterly.
Then they developed the interventions to improve rates: verification and clean-up of their data, physician and staff education, physician incentives, previsit planning, electronic follow-up orders for the second and third doses, reminder calls, manufacturer tools, and clinical summaries.
The physician education program involved first making HPV vaccination a priority even when multiple competing priorities exist at each well visit.
“Our doctors felt, as all doctors feel, that we have 75 things to do and it’s not possible to do them all,” Dr. Casler said. “If we don’t have a fast and dirty way of doing something, it won’t get done.”
Part of prioritizing the vaccine was making physicians aware of how common HPV and HPV diseases were, which many did not realize. Then the training addressed providers’ discomfort about discussing the vaccine. They provided a script that included a clear recommendation for the HPV vaccine – sandwiched between the recommendations for the meningitis and Tdap vaccines – without adding unnecessary extra information unless the parent requested it.
During staff training, her practice found similar obstacles as with the doctors. “They had different competing priorities, they didn’t really know what HPV was, and they didn’t want to talk about sex,” Dr. Casler said.
Following training, they distributed tools such as posters and fact sheets to physicians and developed incentives: competition among each other, a quality bonus structure, and wine. “It’s amazing what will motivate people,” Dr. Casler said with a smile. “Again, this is the real world.”
Daily previsit planning meant documenting on patient lists the priorities for each patient, including the HPV vaccine as well as needs such as flu shots; other vaccines; screening for asthma, depression, and STIs; smoking assessment; diet and exercise counseling; and risk factor assessments.
“That is one of the most valuable interventions and got a tremendous amount of feedback from the staff,” Dr. Casler said. “Any practice can do this for free. I look at every metric that needs to be covered with that patient during that visit.”
Patients then are required to schedule their second and third doses on their way out. “If someone no-shows or doesn’t reschedule, my secretary knows what HPV is and what it does,” Dr. Casler said. “She will call the parents and leave a message, ‘Call me tomorrow to reschedule your appointment... so that your child doesn’t get cancer.”
In evaluating the program, Dr. Casler said the most popular interventions were the physician and staff education programs, scheduling subsequent doses in real time, and using manufacturer-supplied tools such as magnets and cling posters. Staff involvement turned out to be a critical resource in the overall intervention as well.
As a result of the program begun in August 2013, the practice’s rates of girls and boys receiving one dose of the HPV vaccine increased to 65% and 57%, respectively, by the end of 2014. Further, 43% of girls and 30% of boys received all three doses. By June 2016, 75% of girls and 72% of boys were receiving their first dose of HPV vaccine, and 55% of girls and 47% of boys were receiving all three doses.
Dr. Casler reported previous consulting and speaking for Merck and Sanofi Pasteur. No external funding was reported.
ATLANTA – A multifaceted comprehensive intervention significantly improved human papillomavirus (HPV) vaccination rates in a Florida pediatric health care group practice.
Alix G. Casler, MD, chief of pediatrics at Orlando Health Physician Associates, described how her practice put into place practices to improve the overall HPV vaccination rate of their clients.
She described the critical components of a vaccination quality improvement project: set specific goals, know your practice’s actual rates, identify areas of weakness and/or opportunity, and then implement effective and sustainable processes for improvement. Their initial goal was to show any improvement at all in the first year and then to meet the highest national rates 2 years later.
“We started by agreeing we would become transparent to one another,” Dr. Casler explained. “This is called peer influence. What we didn’t want to be was the one who deviated from standard practice.”
As they got further along into their initiative, this transparency led physicians to ask others with better rates for help. “It’s not just a motivator in terms of not wanting to be the worse; it’s also a motivator in knowing how to get help,” said Dr. Casler, also at Florida State College of Medicine in Tallahassee and the University of Central Florida in Orlando.
Individual physicians’ rates were first shared privately with that physician, then shared with the department, and then published monthly and eventually only quarterly.
Then they developed the interventions to improve rates: verification and clean-up of their data, physician and staff education, physician incentives, previsit planning, electronic follow-up orders for the second and third doses, reminder calls, manufacturer tools, and clinical summaries.
The physician education program involved first making HPV vaccination a priority even when multiple competing priorities exist at each well visit.
“Our doctors felt, as all doctors feel, that we have 75 things to do and it’s not possible to do them all,” Dr. Casler said. “If we don’t have a fast and dirty way of doing something, it won’t get done.”
Part of prioritizing the vaccine was making physicians aware of how common HPV and HPV diseases were, which many did not realize. Then the training addressed providers’ discomfort about discussing the vaccine. They provided a script that included a clear recommendation for the HPV vaccine – sandwiched between the recommendations for the meningitis and Tdap vaccines – without adding unnecessary extra information unless the parent requested it.
During staff training, her practice found similar obstacles as with the doctors. “They had different competing priorities, they didn’t really know what HPV was, and they didn’t want to talk about sex,” Dr. Casler said.
Following training, they distributed tools such as posters and fact sheets to physicians and developed incentives: competition among each other, a quality bonus structure, and wine. “It’s amazing what will motivate people,” Dr. Casler said with a smile. “Again, this is the real world.”
Daily previsit planning meant documenting on patient lists the priorities for each patient, including the HPV vaccine as well as needs such as flu shots; other vaccines; screening for asthma, depression, and STIs; smoking assessment; diet and exercise counseling; and risk factor assessments.
“That is one of the most valuable interventions and got a tremendous amount of feedback from the staff,” Dr. Casler said. “Any practice can do this for free. I look at every metric that needs to be covered with that patient during that visit.”
Patients then are required to schedule their second and third doses on their way out. “If someone no-shows or doesn’t reschedule, my secretary knows what HPV is and what it does,” Dr. Casler said. “She will call the parents and leave a message, ‘Call me tomorrow to reschedule your appointment... so that your child doesn’t get cancer.”
In evaluating the program, Dr. Casler said the most popular interventions were the physician and staff education programs, scheduling subsequent doses in real time, and using manufacturer-supplied tools such as magnets and cling posters. Staff involvement turned out to be a critical resource in the overall intervention as well.
As a result of the program begun in August 2013, the practice’s rates of girls and boys receiving one dose of the HPV vaccine increased to 65% and 57%, respectively, by the end of 2014. Further, 43% of girls and 30% of boys received all three doses. By June 2016, 75% of girls and 72% of boys were receiving their first dose of HPV vaccine, and 55% of girls and 47% of boys were receiving all three doses.
Dr. Casler reported previous consulting and speaking for Merck and Sanofi Pasteur. No external funding was reported.
AT THE NATIONAL IMMUNIZATION CONFERENCE
Key clinical point: A multifaceted comprehensive intervention significantly improved HPV vaccination rates in a pediatric health care group practice.
Major finding: Girls and boys receiving any HPV vaccine dose increased from 23% and 12% in 2013 to 75% and 72% in June 2016, respectively. Rates of three doses increased from 14% of girls and 3% of boys in 2013 to 55% of girls and 47% of boys in June 2016.
Data source: The findings are based on internal assessment of an intervention at a large multispecialty health care group with 22 pediatricians and with 23,000 patients at least 11 years old.
Disclosures: Dr. Casler reported previous consulting and speaking for Merck and Sanofi Pasteur. No external funding was reported.