We have some special events planned for IDWeek this year that I want to let you know about in advance. This is the 40th anniversary of PIDS, and we will be celebrating the 40th anniversary all week in San Francisco. In addition to great scientific sessions at IDWeek, I want to call out 3 special events for your participation:

The use of antibiotics drives the development of antibiotic resistance, a major threat to public health worldwide. But these drugs also carry the risk of harm to individual patients, including children. According to a new analysis published in the Journal of the Pediatric Infectious Diseases Society, antibiotics led to nearly 70,000 estimated emergency room visits in the U.S. each year from 2011-2015 for allergic reactions and other side effects in children. The study helps quantify the risk posed by specific antibiotics in children across different age ranges.

“For parents and other caregivers of children, these findings are a reminder that while antibiotics save lives when used appropriately, antibiotics also can harm children and should only be used when needed,” said lead author Maribeth C. Lovegrove, MPH, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention. “For health care providers, these findings are a reminder that adverse effects from antibiotics are common and can be clinically significant and consequential for pediatric patients.”

For their analysis, researchers used nationwide estimates for outpatient antibiotic prescriptions and data from a nationally representative sample of hospitals for emergency room visits attributed to the use of antibiotics by children aged 19 and younger. Most of the visits (86 percent) were for allergic reactions, such as a rash, pruritus (itching), or angioedema (severe swelling beneath the skin). The risk of a visit varied by child age and type of antibiotic, but for most antibiotics, children aged 2 or younger had the highest risk of an adverse drug event. Forty-one percent of visits involved children in this age group. Amoxicillin was the most commonly implicated antibiotic in adverse drug events among children aged 9 or younger, while sulfamethoxazole/trimethoprim was most commonly implicated among children 10-19 years old.

Antibiotics are among the most commonly prescribed medications for children, but prior research has suggested that nearly a third, if not more, of outpatient pediatric prescriptions for antibiotics are unnecessary. Efforts to reduce antibiotic overprescribing have largely focused on reducing antibiotic resistance. However, studies have shown that these longer-term societal risks are not always prioritized when clinicians are making decisions about treatment.

“By considering available data on the immediate risks to individual patients, clinicians, and parents and caregivers, can better weigh the risks and benefits of antibiotic treatment,” Lovegrove said.

The researchers were not able to determine which antibiotic prescriptions were unnecessary or inappropriate in the study, because data for antibiotic indications, doses, and durations of therapy were not available. The study also likely underestimates how often children experience adverse side effects from antibiotics because the analysis includes only adverse drug events that resulted in a visit to an emergency room. Adverse drug events treated in other settings, such as an urgent care facility or a doctor’s office, or cases for which no health care was sought, were not included. Also, adverse events that are less likely to be diagnosed in the emergency room setting (e.g., Clostridium difficile infections that can cause severe diarrhea after antibiotic use) were not included.

Fast Facts

  • Antibiotics are among the most commonly prescribed medications in children, but they can lead to adverse drug events and should be used only when needed.
  • From 2011-2015, antibiotic use in children led to nearly 70,000 estimated emergency room visits each year for allergic reactions and other side effects.
  • The risk of a visit varied by child age and type of antibiotic used, but for most antibiotics, children aged 2 or younger had the highest risk of an adverse drug event.

Click here to read the analysis published in the Journal of the Pediatric Infectious Diseases Society.

Discussions regarding “cost” and “value” seem to dominate every conversation about healthcare these days. In a recent editorial in the Journal of the Pediatric Infectious Diseases Society, PIDS immediate past-president Dr. Gilsdorf and colleagues commented that pediatric infectious disease physicians’ “compensation, which is determined by leaders of pediatric departments and hospitals, does not take into account our overall value to the hospital in clinical and nonclinical work as well as in potential cost-saving activities.” This is an appropriate lead-in to an article published in the June 2018 issue of JPIDS by researchers from Doernbecher Children’s Hospital in Portland, Oregon entitled “Utilizing a Modified Care Coordination Measurement Tool to Capture Value for a Pediatric Outpatient Parenteral and Prolonged Oral Antibiotic Therapy Program.” This article sought to determine the amount of time spent by pediatric infectious disease providers on non-reimbursable care coordination activities in the context of a pediatric outpatient antimicrobial therapy program (OPAT).

In this study, care coordination as related to OPAT was assessed using the “Care Coordination Measurement Tool,” which was previously developed to evaluate the activities that occur within care coordination (CC), the resources needed, and the outcomes impacted. All encounters related to OPAT that included non-reimbursable tasks were recorded over a six-week period, and data regarding the time spent and types of activities performed were collected. Additionally, the OPAT providers prospectively recorded whether an outcome (such as an ER visit) was prevented.

In total, 154 CC encounters were recorded on 29 patients during the time period in question. The most common activity performed during these encounters was “clinical/medical management” (31%) followed by lab management (17%), family/patient advice (15%), and coordination among subspecialty providers (10%). Over the study period, CC activities totaled an estimated 54 hours of non-reimbursable work. Eight patients who lived a long distance from the clinic were managed completely through CC encounters and coordination with local primary care providers and did not have any billable pediatric ID clinic visits. Ten ER visits and two hospital admissions were prevented through CC encounters. The authors concluded that non-reimbursable CC through an OPAT program leads to improved outcomes for both patients and healthcare systems, as well as substantial cost savings (estimated $29,000 of costs avoided in this short six-week period).

This study provides a real-life example of how pediatric infectious disease programs can quantify the value that they add to a healthcare system or hospital outside of “billable clinical activities.” These additional activities may include coordination of OPAT, antimicrobial stewardship, and infection prevention. Similar to this study, providers engaged in these activities can consider prospective recording of time spent and activities performed over a short time period. An estimation of potential negative outcomes avoided, and cost savings could subsequently be presented to hospital and department administration, in order to justify obtaining financial support for providers to carry out these activities. In an era when cost and value are being constantly scrutinized, it is paramount that pediatric infectious disease physicians have a means to demonstrate their value to the system. Studies such as this one provide a framework for such conversations. The value of ID services may be clear to us all, but our ability to demonstrate this to the health systems in which we work will be critical to the future survival and growth of the specialty of pediatric infectious diseases.

-Natasha Nakra, MD

As we begin the 2019 program planning process, the PIDS Program and Meetings Committee (PMC) would like to encourage all members to consider submitting Invited Science session proposals for the Pediatric Academic Societies (PAS) and IDWeek Meetings. If you can recall, the society’s strategy for our major meetings changed to align with our priorities. For the PAS Meeting, we are encouraging programming that focuses primarily on sessions serving the clinical and educational needs of a broader audience, especially ID topics that will be useful to both ID and other specialties represented at this meeting. For the IDWeek Meeting, session proposals should focus on cutting-edge science and emerging infections. Example topic areas for both meetings are listed below.

Example topic areas for PAS from past meetings:

  • Antimicrobial stewardship (Outpatient, Neonatal)
  • Healthcare-associated infections / Infection control
  • Updates on diagnosis and management of bacterial infections
  • Diagnosis, treatment, and prevention of respiratory viral infections
  • Epidemiology and clinical burden of antibiotic resistance
  • Vaccinology/Vaccine communications
  • Neonatal sepsis
  • Epidemiology and management of congenital infections (Zika, CMV, syphilis)
  • Epidemiology, treatment, and prevention of HIV / STIs)

Example topic areas for IDWeek from past meetings:

  • Kawasaki Disease: What’s New
  • The Cutting Edge of Science in Pediatric Transplantation
  • NTM Infections in Children
  • Neurological Manifestations of Infectious Diseases
  • Antimicrobial PK/PD in Maternal-Child Infections
  • The Pediatric Microbiome
  • New Antimicrobials
  • Immunomodulators and Infection Risk in Pediatrics: Everything You Want to Know but Are Afraid to Ask
  • Pediatric Vaccine Consults
  • Red Book Update
  • Mosquitos Migrate and Tuberculosis Travels: Management of Arboviral and Tuberculosis in Latin America and the United States
  • Thinking Outside the Room: Considerations for the Management of Ebola Virus Disease in Children
  • Maintenance of Certification (MOC) in Pediatric Infectious Diseases
  • Human Milk: Its Role in Infant Infection

As you begin thinking about session ideas, the PMC would like to provide you with our review and selection process in an effort to provide transparency and enlighten members on the committee’s process.

Programming Selection Process

  • Call for Session Proposals announcements are sent to the membership for proposal submissions
  • Proposals are submitting through a portal (e.g., Scholar One and Confex) on the conference website; link provided in the announcement
  • Once the deadline has passed, session proposals are forwarded to all PIDS PMC members for review.
  • Committee members review and rank list the session proposals; the proposal rank lists are then averaged and shared with committee members
  • The PMC convenes conference calls to discuss the list of proposals; committee members who have proposed or championed sessions themselves are welcome to present them to the group; however, all submissions will be considered and discussed. Discussion may also include recommendations to combine proposals that are similar thematically, reformulate proposals to align with the specific meeting/audience for which it is being proposed, and/or consider for co-sponsorship with other professional societies, as well as identify and fill gaps in ID programming that the Committee feels are important to include in the programming.
  • After the call, PIDS staff will send out a second spreadsheet in which PMC members will re-rank the proposals and/or revised proposals based on our committee discussion.
  • Based on the responses, the Programs and Meetings Committee co-chairs will make final selections based on the committee’s rankings for submission at each respective meeting.

We have provided a sample proposal for your reference. The PAS Call for Invited Science Proposals announcement will be sent later this summer. The IDWeek Call for Invited Science Proposals announcement will be sent in late September. Please consider submitting your ideas. Feel free to contact me or other committee members should you have any questions or concerns

Archie Chatterjee, MD, PhD, FPIDS
Chair, PIDS Program & Meetings Committee

For several years the AAP Section on Infectious Diseases has been working with the AAP Committee on Coding and Nomenclature to promote the publishing of values for the Interprofessional Telephone/Internet Consultation CPT codes (99446-99449) for specialties that frequently provide telephone advice without formal consultation from other physicians. Infectious Diseases is among the specialties most frequently providing such advice.  We are happy to announce to the PIDS membership that CPT codes for this activity approved in 2014 now have wRVUs assigned for the four codes below which vary only in the amount of time spent in consultation.

  • 99446 Interprofessional telephone/Internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional; 5-10 minutes of medical consultative discussion and review
  • 99447 Same as above; 11-20 minutes of medical consultative discussion and review
  • 99448 Same as above; 21-30 minutes of medical consultative discussion and review
  • 99449 Same as above; 31 minutes or more of medical consultative discussion and review

For 2019, two additional codes will be available, 994X0 and 994X6 [Note: These codes will be assigned permanent code numbers with the release of CPT 2019], the former being a code for the treating/requesting physician and the latter for the consultant. Code 994X6 can be used for Interprofessional telephone/internet/electronic health record assessment and management provided by a consultative physician including a written report to the patient’s treating/requesting physician requiring 5 or more minutes of medical consultative time. This code has been assigned 0.50 wRVUs by CMS although 0.70 was requested by the AMA/Specialty Society Relative Value Scale Update Committee (RUC). The final values will  be published in November 2018. 

Please see the attached report for all codes and assigned wRVUs and discuss with your billing and coding departments on how to implement these codes and receive RVUs for these activities.

“The Challenges of Viral Respiratory Healthcare-Associated Infections in Pediatrics”
Quach C, Shah R, Rubin LG. Burden of healthcare-associated viral respiratory infections in children’s hospitals. JPIDS. 2018; 7(1): 18-24.

It is well known that viral respiratory infections are a common healthcare associated infection (HAI) in children. For those of us who practice in states that have mandatory National Healthcare Safety Network (NHSN) reporting requirements for all HAIs, performing the necessary house-wide surveillance for respiratory viral HAIs (HA-VRI) becomes challenging in terms of time and IP resources especially during respiratory viral season when these viruses are circulating at high rates in the community. The prevalence of HA-VRI in children varies in the literature. There have been many reports of increased morbidity and mortality from HA-VRI especially in neonates and immunocompromised patients 1-4. Hospital laboratories that perform more sensitive testing, such as nucleic acid amplification, will diagnose more respiratory viruses. Detection of respiratory viral nucleic acid may also represent asymptomatic shedding. This is especially a concern for rhinovirus where prolonged shedding can make it unclear if a positive test represents shedding or infection. It is unclear how well the NHSN definitions perform for HA-VRI in children and how best to utilize IP resources to perform surveillance. We lack best practices for HA-VRI prevention and we lack antivirals against the most commonly identified viruses that cause HA-VRI. More information is acutely needed.

The study performed by Quach et al begins to help address some of these issues. They compared and assessed determinants of unit-specific HA-VRI incidence rates in two children’s hospitals during three respiratory viral seasons (2010-2013). This was a retrospective study of prospective cohorts at Montreal Children’s Hospital (MCH) and Cohen Children’s Medical Center (CCMC) in New York. Both hospitals have similar demographics (number of beds, level 4 NICU, PICU, bone marrow transplant unit, hematology oncology ward and general medical/surgical wards). Both hospitals had some wards with multiple beds per rooms. Prospective surveillance for HA-VRI used standard NHSN definitions that require compatible respiratory symptoms and viral detection. Both hospitals used the minimum number of days since admission and viral incubation periods to determine HA-VRI (shortest number of one day for influenza A/B at MCH and longest of 4 days for human metapneumovirus at CCMC). Only MCH conducted syndromic surveillance for HA-VRI. Both hospitals use a multiplex nucleic acid amplification test for viral detection on nasopharyngeal swabs or aspirates; MCH used an in-house assay that detects adenovirus, human metapneumovirus, influenza A and B, parainfluenza types 1,2,3 (PIV), respiratory syncytial virus (RSV), enterovirus, rhinovirus and coronaviruses 229E and OC43. CCMC used the Luminex TM multiplex nucleic acid amplification test which can detect the same viruses, however it cannot detect coronaviruses nor can it differentiate between enterovirus and rhinovirus requiring a supplemental test to differentiate between these two.

HA-VRI rates per 1000 patient days were determined including virus (excluding coronavirus and patients who tested negative but were found by syndromic surveillance) and unit specific rates. Multivariable regression analysis was used to assess determinants for HA-VRI. The HA-VRI rate for the 6 virus groups studied was significantly higher at MCH than at CCMC (1.91 vs 0.80 per 1000 patient-days, respectively, P <.0001). Overall the rate was lowest in the NICU, however units with the lowest HA-VRI rate differed between MCH and CCMC (Heme/Onc ward vs NICU respectively). The rank order of viruses identified was similar between the two hospitals with rhinovirus most commonly identified followed by PIV and RSV. When viral etiology was compared by unit type, the highest rates were in the PICU with rhinovirus followed by adenovirus and Heme/Onc wards with rhinovirus followed by PIV in both hospitals. When adjusted for unit type and HA-VRI they found less than 50% single rooms in a given unit to be statistically associated with a higher rate (1.33 times higher rate (95% CI 1.29-1.37) regardless of unit type, however neither hospital had a NICU with single rooms. The authors speculate that single rooms might not be sufficient to prevent nosocomial acquisition in the absence of meticulous hand hygiene and housekeeping, but since most of these viruses are spread by contact and droplets decreased crowding in single rooms would likely prevent some transmission. Both hospitals had visitor restriction policies due to illness or young age, however both hospitals admitted that their policies were rarely enforced. Staff who were ill were instructed to stay home, but it is not known how well this policy was enforced at either hospital. It is likely that more IP resources would have been required to perform syndromic surveillance at MCH. The authors acknowledged that potential misclassification of some community acquired infections as HAIs might have occurred and systematic HA-VRI surveillance was not performed after discharge so some patients with HA-VRI may not have been identified.

Prevention of HA-VRIs is difficult. Asymptomatic shedding can occur in both healthcare workers (HCW), patients, parents/caregiver and visitors. Ill HCW presenteeism is common and lean staffing results in HCWs coming to work ill because they do not want to burden their colleagues 5,6,7,8. The same lean staffing may affect oversight of ill parents/caregivers and visitors allowing for importation of viruses from the community. The hospital environment quickly becomes contaminated and these viruses are then spread on HCWs hands to patients. Respiratory viruses can persist on dry surfaces from 2 hours-3 months depending on the virus9. There is a need for studies that evaluate best practices for HA-VRI prevention, along with visitor policies that align with family centered care, but which are still safe for other patients and HCWs. We need to ensure healthcare worker non-punitive policies for staying home if ill. In order achieve this we need to have adequate staffing in hospitals so an ill HCW can stay home and daily work can still be completed safely.

Written by: Jane M. Gould, MD

References:

  1. Zinna S, Lakshmanan A, Tan S, McClaughry R, Clarkson M, Soo S, Szatkowski L, Sharkey D. Outcomes of nosocomial viral respiratory infections in high-risk neonates. Pediatrics 2016; 138(5)
  2. Spaeder MC, Fackler JC. Hospital-acquired viral infection s increases mortality in children with severe viral respiratory infection. Pediatr Crit Care Med 2011; 12: e317
  3. Chow EJ, Mermel LA. Hospital-acquired respiratory viral infections: incidence, morbidity and mortality in pediatric and adult patients. Open Forum Infect Dis 2017 4(1)
  4. Simon A, Khurana K, Wilkesmann A, Muller A, Englehart S, Exner M, Schildgen O, Eis-Hubinger AM, Groothuis JR, Bode U. Nosocomial respiratory syncytial virus infection: impact of prospective surveillance and targeted infection control. Int J Hyg Environ Health. 2006; 209(4): 317-24.
  5. Szymczak JE, Smathers S, Hoegg C, Klieger S, Coffins SE, Sammons JS. Reasons why physicians and advanced practice clinicians work while sick: a mixed-methods analysis. JAMA Pediatr. 2015; 169(9): 815-21.
  6. Tan PC, Robinson G, Jayathissa S, Weatherall M. Coming to work sick: a survey of hospital doctors in New Zealand. NZ Med J. 2014; 127(1399):23-35.
  7. Bracewell LM, Campbell DI, Faure PR, Giblin ER, Morris TA, Satterthwaite LB, Simmers CD, Ulrich CM, Holmes JD. Sickness presenteeism in a New Zealand hospital. NZ Med J. 2010; 123(1314): 31-42.
  8. Schneider D, Winter V, Schreyogg J. Job demands, job resources, and behavior in times of sickness: an analysis across German nursing homes. Health Care Manage Rev. 2017 Mar 3. [Epub ahead of print].
  9. Kramer A, Schwebke I, Kampf G. How long do nosocomial pathogens persist on inanimate surfaces? A systematic review. BMC Infect Dis 2006, 6:130-138.

Many parents have questions about their children’s vaccines. Although you may not provide routine immunizations as an infectious disease specialist, you can still serve as a trusted information resource for parents. CDC’s National Center for Immunization and Respiratory Diseases (NCIRD) has a number of resources available to help you talk with parents about vaccines:

For more information, email This email address is being protected from spambots. You need JavaScript enabled to view it. or visit cdc.gov/vaccines

Pediatric ID specialists are viewed by administrators and other physicians as valuable contributors to the delivery of high quality medical care, according to a new study published in Hospital Pediatrics. Their contributions in many areas, however, can be difficult to measure, which may lead administrators to overlook their value and under-allocate resources, the findings suggest.

The study, which was supported by PIDS, sought to identify perceptions that clinical and administrative stakeholders working in hospitals that provide pediatric care have about the value of pediatric ID physicians. Ninety-seven physicians and administrators from five hospitals in different regions of the U.S. were included. Analysis of open-ended, qualitative interviews revealed numerous ways in which pediatric ID specialists are thought to provide value.

Pediatric ID specialists’ perceived contributions to quality care included the effective treatment of patients with unusual infections or those that respond poorly to initial treatment, the optimization of antimicrobial use, and the ability to serve as outpatient homes for complex patients. Interview respondents also indicated that these specialists provide value by facilitating communication with patients, families, and other specialties. Additional perceived contributions included important system- or hospital-wide activities, such as antimicrobial stewardship and infection prevention.

Much of this valuable work, however, is not easily reimbursed by payers or captured by current metrics for physicians’ labor. This uncertainty caused some administrative respondents in the study to question how many pediatric ID specialists and related resources are needed to achieve high quality care, improve patient outcomes, and reduce costs, the study authors found.

The findings build on previous research investigating the value of cognitive specialties that has largely focused on clinical outcomes, such as mortality, readmissions, length of stay, or cost. The study adds to the understanding of how the pediatric ID specialty, in particular, is perceived and is part of PIDS’ ongoing efforts to demonstrate the value of the specialty to the health care system. The study’s lead author is Julia E. Szymczak, PhD, of the University of Pennsylvania Perelman School of Medicine, and other authors include several PIDS leaders.

The latest Journal Citation Reports® have recently been released, and we are excited to announce that Journal of the Pediatric Infectious Diseases Society (JPIDS) has received its first Impact Factor.  The journal's Impact Factor is 2.456.

"This milestone reflects the increasing attention to the high-quality work published in JPIDS and is the result of the ongoing efforts and dedication of the journal editorial team," said Dr. Paul Spearman, President, Pediatric Infectious Diseases Society "We now anticipate greater discoverability and dissemination of our content to the pediatric infectious diseases community and to the wider pediatric community." 

To celebrate this important achievement, we have curated a selection of highly cited articles from recent years and made them free to read online. Read Now

06/25/2018

Paul Auwaerter, MD, MBA, President IDSA
Melanie Thompson, MD, Chair HIVMA
Paul Spearman, MD, FPIDS, President PIDS
Keith Kaye, MD, MPH, FSHEA

Contact

IDSA: Jennifer Morales This email address is being protected from spambots. You need JavaScript enabled to view it.

PCI Public Relations (312) 558-1770 This email address is being protected from spambots. You need JavaScript enabled to view it.

The consequences to individual and public health of continuing “zero-tolerance” border policies and of large scale detention of thousands of weakened and vulnerable individuals will be longstanding and far-reaching.

The separation of immigrant families at our borders has run counter to principles of promoting wellbeing and preventing disease, as well as of prioritizing compassion, empathy and the best interests of children that must be part of any healthy society. That separation has challenged the first step in the most basic health services of collecting medical histories, including of immunizations. While Department of Health and Human Services and U.S. Centers for Disease Control and Prevention policies provide immunizations and basic health exams for unaccompanied minors, immigrants and refugees, whether these policies are being followed remains unclear at best.

All detained persons should be provided appropriate hygiene including access to soap, showers, clean clothes, safe water, access to appropriate healthcare, and to the best practices that protect the health of individuals and the public.

Basic practices of hygiene and infection prevention have already been demonstrated to be lacking, with reported outbreaks of chicken pox as well as scabies and other infections among those detained, indicating just some of the potential for widespread transmission of illnesses the policy has created. The possibilities for the spread of tuberculosis and other airborne diseases, including measles, as well as vector-borne illnesses, including ones resistant to antibiotics, continues to concern us.

As organizations of more than 12,000 infectious diseases, pediatric infectious diseases and HIV physicians, as well as healthcare epidemiologists, the Infectious Diseases Society of America, the HIV Medicine Association, the Pediatric Infectious Diseases Society and the Society for Healthcare Epidemiology of America call for speedy reunification of children with their families.  We remain deeply concerned that the policy of detaining large numbers of people, including entire families is leading to conditions that can fuel the spread of infections, and call for a thorough evaluation of the conditions and the consequences of their detention and of the public health ramifications.

 

House Passes Bills that Address Infections Related to the Opioid Epidemic

6/13/2018

Statement of the Infectious Diseases Society of America, the HIV Medicine Association and the Pediatric Infectious Diseases Society 

Contact: IDSA: Jennifer Morales This email address is being protected from spambots. You need JavaScript enabled to view it.

PCI Public Relations (312) 558-1770 This email address is being protected from spambots. You need JavaScript enabled to view it.

The U.S. House of Representatives voted overwhelmingly last night to approve the Eliminating Opioid-Related Infectious Disease Act and the Substance Use Disorder Loan Repayment Act of 2018. The Infectious Diseases Society of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society strongly support these bills. They will expand surveillance of infections (including HIV, hepatitis B and C, endocarditis, and other communicable health threats) associated with substance use disorders, authorize provider training to coordinate care for both infectious diseases arising from substance use and addiction, and provide loan repayment for health professionals caring for patients with substance use disorders (including those treating related infections).

As Societies with more than 12,000 infectious diseases, pediatric, and HIV physicians, IDSA, HIVMA, and PIDS made recommendations reflected in the Eliminating Opioid-Related Infectious Diseases Act, including the addition of endocarditis, a heart valve infection, to the list of infections related to the opioid epidemic. Not currently under national surveillance, endocarditis in most cases is a severe, acute illness requiring hospitalization that is different from viral infections associated with injection drug use such as HIV and hepatitis C virus (HCV).  For HIV and HCV, individuals can live with the conditions for years before prominent symptoms occur requiring acute care and engagement with the medical system. Surveillance or monitoring of endocarditis and other bacterial infections will lead to more timely identification of injection drug-related outbreaks. We also strongly support the provider training component of the bill and are pleased that the bill now recognizes the importance of training and care coordination for infectious diseases and addiction to help ensure better patient outcomes.

The Substance Use Disorder Loan Repayment Act will address the need for a trained health workforce sufficient to detect, control and deliver coordinated care for infections with an escalating incidence as a result of increasing injecting drug use. Compared to five years ago there are 20 percent fewer physicians entering training programs for infectious diseases and HIV medicine, raising great concern about shortfalls in expertise exactly when most needed. This bill will help to attract the diversity of healthcare providers necessary to provide prevention, care, and treatment services to individuals with substance use disorders, including infectious diseases and HIV providers.

These bills are part of a package of legislation passed by the House yesterday to address the opioid crisis, and the effort reflects a bipartisan commitment to confronting the combined public health threats of the growing opioid epidemic and the outbreaks of infectious diseases the crisis has fueled. We urge the U.S. Senate to advance these measures so that they may rapidly become law.

The SECURE -- Securing Experts to Control, Understand, and Respond to Emergencies -- Act (HR 5998), a bill that would establish Epidemic Intelligence Service student loan repayment at the Centers for Disease Control and Prevention, was introduced today by Rep. Jan Schakowsky (D-IL). This bill would represent a critical step in strengthening the infectious diseases public health workforce by allowing medical school loan repayment for physicians participating in the CDC’s two-year public health emergency preparedness and response fellowship program.
 
While similar programs at NIH and HRSA’s National Health Service Corps offer loan repayment to encourage careers in biomedical research and patient care in underserved communities, that opportunity does not now exist for careers in public health preparedness and response. HR 5998 would fill this gap.
 
IDSA was instrumental in developing this proposal, and is urging its passage. PIDS is assisting IDSA in spreading the word to our members.  Please take two minutes now to ask your representative to co-sponsor HR 5998.
 

Dinny was Professor of Community Paediatrics from late 1995, as well as a highly experienced specialist in Pediatric Infectious Diseases with many years of service to Starship (and previously Princess Mary Hospital), Kidz First/Middlemore Hospital and the University of Auckland since 1977. She was hugely respected as an academic researcher in the field both in New Zealand and internationally with over an impressive portfolio of publications. Dinny was an international expert in Rheumatic Fever and instrumental in researching and developing successful school based prevention programs which are a testament to her passion and persistence in developing timely access to quality health services on behalf of our children.

From 2002, when meningococcal disease was at epidemic levels, Dinny worked tirelessly at the national and international level in developing a vaccine and then setting up and leading clinical trials culminating in mass MeNZB vaccination program in 2004 -2008. Dinny was a champion in involving local communities and schools from the start. Her passion to reduce the inequitable burden of infectious diseases in our child community is an example to us all and will be her lasting legacy. Her career achievements will have touched many generations of New Zealand children as well as pediatricians who benefited from her wisdom and teaching.

This news will be a shock to many, as it has been to us. Her passion, leadership, and tenacity to improve the health of disadvantaged children will be sorely missed and remembered with great fondness - moe mai ra e te rangatira.

We send our love and condolences to her husband John, children William and Harry, and their families

Kua hinga te tōtara i Te Waonui a Tāne.
A mighty tōtara has fallen in the forest of Tāne.

Pediatric infectious diseases is an exciting, rewarding, and intellectually stimulating specialty, as well as one that is critical to maintaining good health in children and adolescents. Despite these characteristics, however, there are concerns that too few young physicians are entering the field to meet growing needs.

A new commentary published in JPIDS examines the looming shortage of physicians pursuing pediatric ID, factors behind the problem, and possible solutions to address it. Drawing on physician surveys, recent ID fellowship program match results, and perceptions of both compensation trends and available employment opportunities, the commentary describes the current state of the specialty and implications for the future. Led by Janet R. Gilsdorf, MD, of the University of Michigan Medical School and a past president of PIDS, the commentary authors also suggest ways forward. These include a list of practical steps pediatric ID physicians should take at their own institutions today to attract medical students and residents to the field.

Additional authors of the new commentary, “Pediatric Infectious Diseases Meets the Future,” are Paul Spearman, MD, of Cincinnati Children’s Hospital Medical Center; Janet A. Englund, MD, of the University of Washington in Seattle; Tina Q. Tan, MD, of Northwestern University Feinberg School of Medicine in Chicago; and Kristina A. Bryant, MD, of the University of Louisville School of Medicine.

Prevalence of Pertussis Antibodies in Maternal Blood, Cord Serum, and Infants from Mothers With and Those Without Tdap Booster Vaccination During Pregnancy in Argentina

Fallo AA et al. Journal of the Pediatric Infectious Diseases Society, Volume 7, Issue 1, 19 February 2018, Pages 11–17, https://doi.org/10.1093/jpids/piw069

Pertussis-related morbidity and mortality are highest among infants. In 2012, the Advisory Committee on Immunization Practices recommended Tdap vaccination for all US pregnant women during their third trimester, irrespective of their immunization status. Few studies have evaluated the optimal time for immunizing pregnant women. A study by Fallo and colleagues examined the kinetics of pertussis toxin immunoglobulin G levels (IgG-PT) among infants born to mothers immunized with the Tdap vaccine during pregnancy in Buenos Aires, Argentina.

Healthy pregnant women (aged 18-44) who delivered a singleton child at a public hospital and had not received a Tdap vaccine since 6 years of age were enrolled from 2011 to 2012 (n=99); women who delivered their child at the same center and received a Tdap vaccination were recruited from 2013 to 2014 (n=105). The control group was healthy non-pregnant women aged 18-44 (n=69). Women with current or chronic medical conditions and women with antibody levels suggestive of recent pertussis infection were excluded, along with newborns with a birth weight <2000 g. There were no significant differences in demographics or exposure to household children/adolescents among the three groups of subjects. The mothers received their Tdap vaccine at, on average, 13.2–36.6 weeks.

Paired maternal and umbilical cord blood samples were collected at the time of delivery, processed and frozen at −20°C until blind testing at the Argentina National Reference Center. IgG-PT level was measured using a Centers for Disease Control and Prevention–validated specific pertussis IgG enzyme-linked immunosorbent assay (ELISA). Purified pertussis toxin (Protein Express, Inc, Cincinnati, OH) was used as the positive control. The assay was calibrated to the World Health Organization international reference standard, 06/140. The lower limit of quantification was 1 ELISA unit (EU)/mL. In each assay, values lower than 1 EU/mL were assigned a value of 0.5 EU/mL.

IgG-PT concentration of >20 EU/mL at birth is considered “seropositive” with ≥5 EU/mL defined as the protective level.   In this study nonpregnant women had significantly higher concentrations of IgG-PT than the pregnant women who were not vaccinated (IgG-PT GMCs were 14.4 EU/mL (95% CI, 10.2–20.1 EU/mL; range, 2.7–85.5 EU/mL) and 9.8 EU/mL (95% CI, 8–12.1 EU/mL; range, 0.5–68.1 EU/mL respectively; p=0.03); 16 (16.1%) of the pregnant women had an IgG-PT level of <5 EU/mL.  Lower antibody level among non-vaccinated pregnant women was thought to be due to the immune modulation observed during pregnancy. At birth, the mothers with and without a Tdap vaccine had serum IgG-PT geometric mean concentrations (GMCs) of 35.1 and 9.8 ELISA units (EU)/mL, respectively (P < .0001); cord blood GMCs were 51.3 and 11.6 EU/mL, respectively (P < .0003); cord blood IgG-PT levels were <5 EU/mL in 2.9% and 16.1% respectively (P < .001). There was a linear correlation in IgG-PT levels between paired mother and cord serum samples. The IgG-PT level was <5 EU/mL in 3 (2.9%) of 105 immunized mothers and 33 of 105 (31.4%) had a level of <20 EU/mL. 2 of 105 (1.9%) cord samples had an IgG-PT level of <5 EU/mL.  Vaccination timing had no impact on maternal or cord serum levels; however, there were lower antibody levels at delivery in mothers vaccinated before 20 weeks of gestation. No correlation was found between cord IgG-PT concentrations and maternal age or infant birth weight.

Cord blood IgG-PT levels were higher than those of maternal serum. Placental antibody transference efficiencies (the ratio of cord blood GMC to maternal GMC) were 1.46 and 1.18 for mothers with and those without a Tdap vaccination, respectively. 

After birth, the investigators analyzed the IgG-PT kinetics in newborns born to immunized mothers.  The IgG-PT GMCs were 17.7 EU/mL in 36 infants in their first month of life and 11.6 EU/mL in 32 infants in their second month of life, representing decreases of 76% and 63.5%, respectively, from cord sample levels. This decay was earlier than that suggested by Van Savage et al.  (1) and predicted by Eberhardt et al (2). Therefore, the investigators proposed that an antibody level higher than 20 EU/mL at birth was desirable.  All infants with a IgG-PT GMC higher than 20 EU/mL at birth had a level of >5 EU/mL at 2 months of age; however, 20 of 105 (19%) had a cord level of <20 EU/mL.  No infants in this study developed pertussis. Figure 3 shows the decay of IgG-PT in infants during their first 1 and 2 months of life. 

The authors concluded that infants born to immunized mothers had significantly higher antibody levels during the first 2 months of life, and suggested that more prospective studies to determine the optimal timing of Tdap vaccination during pregnancy.

References