How do we overcome the mindset of anti-vaccinators, a.k.a. anti-vaxers? I sat down with Adam Strasberg1, a political strategist and ad creator, to discuss how to improve the medical community’s approach to vaccine advocacy. He gave me new perspectives on the issue with insights on behavioral economics, ethnography, and the mindset of the lay person.

  1. Brute force does not work. Drilling more science into the minds of college-educated anti-vaxers does not work and may actually produce contradictory results. Nyhan et al. recently published two articles showing current scientific-based public health communications may actually increase misperceptions or reduce vaccination intention with MMR and influenza vaccine.
  2. Emotions matter. Communication is more than just about being on message. Personal stories influence more than the scientific data. Emotions move more than facts. The rise of social networks, blogging and instant internet access on handheld devices has empowered all-comers to tell their stories. Professional degrees are not needed, and are often a hindrance to telling good stories. We, as doctors, need to improve our story-telling techniques. To support the science, we also need to talk about the college freshman we cared for who was left without legs from meningococcal infection or the 6 year old boy who died from the “strangling angel” diphtheria this year in Spain. Stories are emotion delivery vehicles.
  3. Young pediatricians need more experience. Because our vaccines have been so successful, graduating pediatricians today have never seen chicken pox let alone polio or measles. How can they powerfully tell stories about patients they have never cared for? Some effective ways to stir emotion in our trainees beyond lecturing and showing pictures are: 1) Send them abroad. One case of neonatal tetanus or watching a child die from Hib meningitis knowing that the illness was preventable by vaccination will remain etched in their memories for a lifetime. 2) Bring all of your trainees to see the child with exposed muscle following surgery for group A strep necrotizing fasciitis. Remind them that these patients were common before the varicella vaccine. Take them to the pertussis baby on ECMO in the PICU. All trainees should at least see the pertussis cough video. 3) Bring in patients who have recovered from meningococcemia or dealt with HPV and cervical cancer to talk about their experiences. Our trainees understand the science but they will be better vaccine promoters if they also understand the emotions.
  4. Community immunity. Belonging to a community can be a powerful motivator. Everyone wants to be a part of a community. Members of a community feel responsible to help and contribute to their community. Using the phrase “herd immunity” creates the wrong frame for anti-vaxers. A herd follows unthinkingly; most anti-vaxers do not want to be part of a herd. The terminology should be changed to “Community Immunity,” to incite a sense of belonging and purpose.
  5. Mother vaccine spokesperson wanted. We need to reconsider how the medical profession is delivering the message on vaccines. Currently, pro-vaccine spokespersons are experienced male doctors who are revered in the scientific world for their enormous contributions to vaccine science. However, anti-vaxers frequently view them as patriarchs in a social system in which males hold primary power. Anti-vaxers are often young, educated new mothers who want no part of this historically patriarchal society. While there is value in male physicians providing vaccine guidance, the pro-vaccine messages additionally should be articulated in our media sources by women who are mothers as well as doctors. They can more effectively start the discussion with, “I know that you want to do what is best for your children...”
  6. Understand what drives Anti-Vaxers. We continue to speak of vaccination as a public health and science issue, despite the inability of those constructs to influence anti-vaxers. Instead of speaking to parental rights, perhaps we should focus more on protecting innocent children. Instead of promoting science, we should emphasize the naturalness of the vaccination process – it is not a scientific or artificial occurrence, but a natural one, akin to lifting weights to get stronger. We need more research to understand the levers that move anti-vaxers so we can learn to speak with metaphors and constructs that influence them to reconsider their objections. Our children deserve it!

Written by: Pia S. Pannaraj, MD, MPH
Children's Hospital Los Angeles

1 Adam Strasberg is the son of acting teachers. He was raised in the world of actors, theatre and books. With an MFA from NYU Graduate Film School, Adam eschewed the bright lights of Hollywood, instead finding his element fusing his creative talent with his desire for social change inside the world of politics. He is a partner at a marketing consulting firm in Washington, DC. He can be reached at This email address is being protected from spambots. You need JavaScript enabled to view it.

Article summary
In the June issue of the Journal of the Pediatric Infectious Diseases Society, Schwartz and colleagues describe their experience with invasive fusariosis, a relatively rare but often fatal infection. This is a retrospective review of all cases of culture-proven, invasive Fusarium in immunocompromised children at a large, tertiary care facility from 1996-2011. Of 13 children at the authors' institution with positive cultures for Fusarium species, 5 were immunocompromised hosts with invasive infection. Four of the 5 children described previously underwent hematopoietic stem cell transplant (HSCT) with subsequent prolonged neutropenia. All 5 cases had lung involvement, while 2 had skin findings, 2 had brain involvement, and 1 had a positive blood culture for Fusarium. All cases were treated with amphotericin B, while 3 also received voriconazole, and 1 child received granulocytes. Four of the cases were coinfected with bacteria, viruses, or other fungi. All 4 of the children who had undergone HSCT died, with Fusarium believed to be a contributing cause of death.

In addition to these 5 cases, the authors reviewed all reports of invasive Fusarium infections in children available in the literature, summarizing 33 published cases from 1973 to 2012. In this review, the skin (21 cases) was the most common site of infection, followed by blood (14) and lung (11), with brain (3) and sinuses (2) reported less frequently. Treatment was variable, though amphotericin was the most common antifungal used, reported in 25 cases.

Fusarium species are second only to Aspergillus spp. as the most frequent mold implicated in human infections, with invasive disease occurring almost exclusively in immunocompromised hosts. Given the high mortality rate, relative resistance to antifungals, and interspecies variability in susceptibility profiles, treatment of infections due to Fusarium spp. remains a challenge for both adult and pediatric infectious disease physicians. Furthermore, the paucity of available pediatric data introduces an added layer of difficulty in the management of these often complicated patients. In addition to nicely summarizing the available pediatric literature on invasive fusariosis, the article by Schwartz et al also reinforces some important features of Fusarium infections in children.

First, despite reports of the changing epidemiology of fungal infections in children and adults with cancer,1,2 invasive fusariosis remains an uncommon diagnosis. A previous retrospective study reported an overall incidence of ~6 cases per 1000 HSCT, higher in allogeneic compared to autologous transplants.3 While the present article does not report the local incidence, with only 5 cases in a 15 year period at a location with the highest number of new cancer diagnoses and HSCTs in Canada, it seems unlikely to be significantly higher than that previously reported. Second, the authors highlight the variability in treatment of these patients. Although the majority of children received amphotericin, there was inconsistency in the use of combination therapy and adjunctive therapies, such as granulocyte colony stimulating factor and granulocyte transfusion. Finally, it appears that although the prognosis remains poor we may be making progress. Mortality in this series remains high at 50%, but this is an improvement compared to 92% mortality rates reported less than 30 years ago.4 This is likely multifactorial, reflecting differences in the management of patients with malignancy, improvements in diagnostic techniques, changes in the use of antifungal agents, and overall advancements in medical care, among others.

Another noteworthy finding of this case series is the number of coinfections. In the 5 cases described by the authors, 4 had at least one other pathogen detected: 1 child had Staphylococcus aureus, 1 had Aspergillus fumigatus, 1 had both adenovirus and cytomegalovirus (CMV), and 1 had both CMV and Stenotrophomonas. Although a high rate of coinfection has been described in patients with invasive pulmonary aspergillosus5, this has not been widely studied in patients with fusariosis and may have potential implications for both the pursuit of additional diagnostic evaluation following detection of Fusarium spp. and empiric antimicrobial therapy.

Due to its infrequent occurrence and uncertain applicability of in vitro susceptibilities, the optimal management of patients with invasive fusariosis remains unclear. A number of questions have yet to answered, including the role of combination antifungals and adjunctive therapies, such as granulocyte transfusion. This article underscores the need for continued research into this often fatal disease in order to provide evidence-based recommendations for diagnosis and management. --Rebecca Wallihan, MD


  1. Ben-Ami R, Lewis RE, Raad, II, Kontoyiannis DP. Phaeohyphomycosis in a tertiary care cancer center. Clin Infect Dis. Apr 15 2009;48(8):1033-1041.
  2. Maron GM, Hayden RT, Rodriguez A, et al. Voriconazole prophylaxis in children with cancer: changing outcomes and epidemiology of fungal infections. Pediatr Infect Dis J. Dec 2013;32(12):e451-455.
  3. Nucci M, Marr KA, Queiroz-Telles F, et al. Fusarium infection in hematopoietic stem cell transplant recipients. Clin Infect Dis. May 1 2004;38(9):1237-1242.
  4. Richardson SE, Bannatyne RM, Summerbell RC, Milliken J, Gold R, Weitzman SS. Disseminated fusarial infection in the immunocompromised host. Reviews of infectious diseases. Nov-Dec 1988;10(6):1171-1181.
  5. Georgiadou SP, Kontoyiannis DP. Concurrent lung infections in patients with hematological malignancies and invasive pulmonary aspergillosis: how firm is the Aspergillus diagnosis? J Infect. Sep 2012;65(3):262-268.

It's been quite a year in vaccine news. The year has been full of triumphs and full of gloom – from the declaration of polio almost being eradicated in Africa1 to the return of vaccine-preventable diseases like measles in the United States2. We felt the palpable fear of acute flaccid paralysis due to enterovirus D683 to the media hysteria of Ebola. And we celebrated the achievements of vaccine immunologists with the successful trials of the Ebola vaccine4 while dealing with the mismatched prediction for last year's influenza season5. In many ways, the news has captured the entire cycle of public perception of emerging infectious diseases and vaccination – from fear to triumph to forgetfulness of the dangers of vaccine-preventable diseases to suspicion over the value of routine vaccination.

Although these cycles have always occurred throughout the history of modern vaccination, the events of the past 18 months have felt more jumbled as numerous emerging infectious diseases and vaccine-preventable diseases have dominated the public consciousness. And unfortunately, many children continue to suffer from vaccine-preventable diseases due to lack of access to vaccines or misguided parental mistrust6.

But maybe the tide of public opinion is shifting. In a recent survey from the Public Policy Institute of California, over 65% of California adults agreed that children should be vaccinated in order to attend public school7. This public sentiment, along with advocacy from California State Senator and Pediatrician Dr. Richard Pan, eventually culminated in the passage of SB277 in California eliminating public belief exemptions in children attending public school8. In doing so, they joined Mississippi and West Virginia as the only states that do not allow personal belief exemptions. As a California resident, I am amazed at this turn of events. It was only a few years ago, we were watching personal belief exemption rates rise, celebrity talking heads rallying against vaccination, vilification of the human papilloma virus vaccine, and erosion of confidence in the vaccine schedule. While there is still a vocal minority espousing many of these misguided sentiments, there appears to be a change in overall public opinion.

What caused this change? There's no doubt that the California measles outbreak was a major factor in raising awareness about vaccine-preventable diseases. In addition, the recent pertussis outbreaks in California reinforced the importance of vaccination and herd immunity. Finally, there was the general concern surrounding the West Africa Ebola outbreak, MERS-coronavirus, and Enterovirus-D68. Perhaps it was all of these fear-inducing events that led to change. There's no doubt that fear is a powerful motivator. Researchers recently demonstrated that the best strategy in changing people's minds about vaccination was to communicate the dangers of a child getting measles or mumps9. But fear to change minds can only accomplish so much for so long. The real challenge is to continue to affect change when people forget about the fear. This is why the efforts of advocates like Dr. Pan in passing SB277 are so important. This will lead to lasting public policy change to improve public health and to protect children from vaccine-preventable diseases. But the battle is not over. Anti-vaccine groups have already vowed to fight SB277 in the courts and at the ballot box. And they have already targeted individual lawmakers who supported the bill. Dr. Pan's efforts have been met with death threats and a petition to recall him.

In the end, our mission as PIDS members doesn't change: continue to advance the science of vaccines, continue to communicate the safety and efficacy of vaccines, and continue to advocate for common sense public policy to increase vaccination coverage. As we celebrate the 60th anniversary of the polio vaccine and the prospect of a polio-free world, let's press forward to achieving our goal of "Freedom from infections for all children". --David K. Hong, MD


  1. McNeil DGJ. A Milestone in Africa: No Polio Cases in a Year. The New York Times 2015 8/11/2015.
  2. Zipprich J, Winter K, Hacker J, et al. Measles outbreak--California, December 2014-February 2015. MMWR Morb Mortal Wkly Rep 2015;64:153-4.
  3. Greninger AL, Naccache SN, Messacar K, et al. A novel outbreak enterovirus D68 strain associated with acute flaccid myelitis cases in the USA (2012-14): a retrospective cohort study. Lancet Infect Dis 2015;15:671-82.
  4. Henao-Restrepo AM, Longini IM, Egger M, et al. Efficacy and effectiveness of an rVSV-vectored vaccine expressing Ebola surface glycoprotein: interim results from the Guinea ring vaccination cluster-randomised trial. Lancet 2015.
  5. Flannery B, Clippard J, Zimmerman RK, et al. Early estimates of seasonal influenza vaccine effectiveness - United States, January 2015. MMWR Morb Mortal Wkly Rep 2015;64:10-5.
  6. The Editorial Board. Children Die Because People Are Wrongly Afraid of Vaccines. The New York Times 2015 August 20, 2015.
  7. PPIC Statewide Survey: Californians and Their Government. Public Policy Institute of California, 2015. at 
  8. Mello MM, Studdert DM, Parmet WE. Shifting Vaccination Politics - The End of Personal-Belief Exemptions in California. N Engl J Med 2015.
  9. Horne Z, Powell D, Hummel JE, Holyoak KJ. Countering antivaccination attitudes. Proc Natl Acad Sci U S A 2015;112:10321-4.

Since the chickenpox vaccine became available in the U.S. in 1995, there has been a large reduction in chickenpox cases. Hospitalizations and outpatient visits for chickenpox have continued their decline after a second dose of the vaccine was recommended to improve protection against the disease, according to a new study published in the Journal of the Pediatric Infectious Diseases Society. The findings also suggest that increasing vaccination coverage against the once common childhood illness helps protect those who are not immunized themselves.

Chickenpox, also known as varicella, is a highly contagious and sometimes serious disease caused by the varicella-zoster virus. In people who are not vaccinated, it typically causes a blister-like rash, itching, fatigue, and fever. Before the vaccine was available in the U.S. in 1995, about 4 million people would get chickenpox nationwide each year, according to the Centers for Disease Control and Prevention (CDC). Nearly 11,000 people were hospitalized annually, and 100 to 150 people died. A second dose of the vaccine was recommended in 2006.

In this latest study, CDC researchers Jessica Leung, MPH, and Rafael Harpaz, MD, MPH, drawing on national health care claims data from 1994 to 2012, found that there were 93 percent fewer hospitalizations for chickenpox in 2012 compared to the period before the vaccine was introduced. During the two-dose varicella vaccination period (2006-2012), hospitalizations declined 38 percent. Outpatient visits for the illness also dropped significantly. There were 84 percent fewer outpatient visits in 2012 versus the pre-vaccination period. During the two-dose varicella vaccination period (2006-2012), outpatient visits declined 60 percent.

"We found that, in our study, rates for varicella in the U.S. continued to decline as the varicella vaccine program has become fully implemented," said Leung, the study's co-author. "We saw significant declines in rates of varicella after the one-dose vaccine was recommended in 1995 in the U.S., and we're continuing to see additional declines in varicella after two doses were recommended in 2006."

The largest declines were among children and adolescents 1 to 19 years old, a population targeted for vaccination against chickenpox. But the researchers also saw substantial declines in outpatient visits and hospitalizations among infants younger than 12 months, for whom the vaccine is not recommended, and in adults, who are often not immunized, suggesting the possibility of herd immunity. "The surrounding population that can be vaccinated are not getting sick, and therefore the data suggest that these infants are also being protected," Leung said. "We're seeing that for adults as well."

The study also found a considerable rise—from 6 percent in 2003 to 17 percent in 2012—in the proportion of outpatient visits for chickenpox in which patients were tested for the disease. The authors noted that lab testing will become increasingly important for distinguishing chickenpox from other similar rash conditions as cases of chickenpox continue to decline and health care providers become less familiar with its clinical presentation, and the increasing proportion of chickenpox cases among people are who are vaccinated, which are typically mild and difficult to diagnose based on symptoms alone.

Impact of the Maturing Varicella Vaccination Program on Varicella and Related Outcomes in the United States: 1994–2012


Published quarterly, the Journal of the Pediatric Infectious Diseases Society represents the spectrum of peer-reviewed, scientific and clinical information on perinatal, childhood, and adolescent infectious diseases. The journal is a publication of the Pediatric Infectious Diseases Society (PIDS), the world's largest professional organization of experts in the care and prevention of infectious diseases in children.

PIDS membership encompasses leaders across the global scientific and public health spectrum, including clinical care, advocacy, academics, government, and the pharmaceutical industry. From fellowship training to continuing medical education, research, regulatory issues and guideline development, PIDS members are the core professionals advocating for the improved health of children with infectious diseases both nationally and around the world, participating in critical public health and medical professional advisory committees that determine the treatment and prevention of infectious diseases, immunization practices in children, and the education of pediatricians. For more information, visit

I had a hallway consult from one of our pediatric hospitalists recently about a toddler with a clear cut case of Kawasaki disease who had been discharged from the inpatient unit. Her question was straightforward, about aspirin dose and duration, and she added at the end of our conversation "I assumed you didn't want to see the patient, since it was uncomplicated." I was taken aback at first, and as I digested this brief encounter I realized why. Just a few years ago our service would have been involved in every case of Kawasaki disease in the hospital either in consultation or as the primary service. I wondered if we are facing competition from our hospitalist colleagues.

Pediatric hospital medicine has been one of the fastest growing sub-specialties within pediatrics. The American Academy of Pediatrics formally recognized pediatric hospital medicine as a discrete area of practice in 1999. In the past 15 years hospitals have increasingly adopted the hospitalist model of care in the inpatient setting. 1,2 It is estimated that about 3000 Pediatric Hospitalists practice in the United States. 3 Hospitalists have taken a wide role in caring for children including direct inpatient care, medical consultation, procedures, outreach clinic and teaching.4

As the field of Pediatric Hospitalist Medicine grows it will present new challenges and opportunities to our subspecialty. As hospitalists gain more experience and confidence they will feel comfortable caring for children with more common bread-and-butter infectious diseases such as complicated pneumonia, osteomyelitis, intra-abdominal abscess, meningitis and even Kawasaki disease, perhaps without involving Pediatric Infectious Diseases. We may find ourselves in competition with our colleagues in the hospital setting. Unlikely most other sub specialist we do not have a unique set of procedural skills, such as endoscopy or placing tubes and lines which would give us a defined niche and job security. Our specialty is primarily cognitively based and this makes us a bit more vulnerable.

Even more concerning is the competition that we face for residents entering fellowship programs. Our subspecialty has had a very challenging year filling fellowship positions. Hospitalist positions have become very attractive and popular options for graduating residents. It is likely that we are finding ourselves in a competition for candidates for fellowship. Although the number of fellowships in hospital medicine is growing, most hospitalist jobs do not require training beyond residency. As residents carry a larger and larger debt load from medical school, the ability to pay off students loans earlier by taking a hospitalist position right out of residency, as an alternative to pursuing a fellowship becomes attractive. In addition, the 2014-15 Association of Academic Administrators in Pediatrics national compensation survey reported that median salaries for assistant professor hospitalists were $157,165 as compared with assistant professor in pediatric infectious diseases of $134,464.

In many institutions hospitalists are taking leading roles in medical student and resident education, as well as hospital administrative roles, areas where Infectious Diseases has always had a solid presence. As quality improvement and outcomes based care become more important to administrators and payors, hospitalists have embraced these areas. Much of the research published in hospitalist journals is on quality improvement and resource utilization.

So how do we best interact with this youngest of pediatric specialties? First we need to point out to our colleagues the added value to patient care of a Pediatric Infectious Disease consult. Our knowledge of antimicrobial therapy, microbiology and immunology and our ability to understand and interface with the laboratory are all strengths we add to the clinical care of patients. The ID specialist also plays an important role in the transition to home or outpatient care. A study in 2013 demonstrated that ID consultations were associated with improved patient care outcomes, including lower mortality, lower readmission rates, length-of-stay, and costs.5 In addition, sub-sub specialty areas such as transplant infectious diseases are areas we can grow and differentiate ourselves. We have long been advocates of quality improvement in infection control and antimicrobial stewardship and we must continue to show our value to hospital administrators and to our clinical colleagues. Lastly, the lifeblood of any subspecialty is a robust supply of trainees. We must improve our ability to attract residents to our field and show them what a rewarding career they can have in pediatric infectious diseases.
--Gregory DeMuri, MD


  1. Wachter RM. Hospital medicine in 2015: Remarkable successes and a crucial crossroads. J Hosp Med 2015.
  2. Wachter RM. The hospitalist field turns 15: new opportunities and challenges. J Hosp Med 2011;6:E1-4.
  3. Friedman J. The hospitalist movement in general pediatrics. Curr Opin Pediatr 2010;22:785-90.
  4. Freed GL, Brzoznowski K, Neighbors K, Lakhani I, American Board of Pediatrics RAC. Characteristics of the pediatric hospitalist workforce: its roles and work environment. Pediatrics 2007;120:33-9.
  5. Schmitt S, McQuillen DP, Nahass R, et al. Infectious diseases specialty intervention is associated with decreased mortality and lower healthcare costs. Clin Infect Dis 2014;58:22-8.

The Journal of the Pediatric Infectious Diseases Society has been accepted for MEDLINE indexing!

About a week ago, I sat down to fill out my annual review at the academic institution where I work. As part of this, I listed the goals I would like to attain over the coming year. Each goal is assigned a category, and while some categories are easy to fill, such as academic research, the "clinical productivity" category remained blank. I struggled to identify my goal in this area.

The changing landscape of medicine has resulted in various compensation mechanisms for physicians, such that models once seen mainly in private practice are bleeding into academic institutions. This results in changes in how physicians are paid as we move toward models that align targets for volume and quality. As a pediatric ID physician, I normally do not give much thought to the number of patients that I see when I am in clinic or on service – that may need to change soon. Now that our hospital has moved to a primarily Relative Value Units (RVU) productivity based system, I must now think about numbers, complexity, and time. This feels foreign to me, as I picked a career I loved without much thought or consequence of these real life issues of "compensation" and "benchmarking." Pediatric ID is not traditionally seen as "revenue generating" compared to other specialties1. This bodes for particular concern for cognitive specialties limited by referrals and with few, if any, profitable procedures.

The major models by how pediatric ID physicians are compensated are varied and changing2. Pure 100% salary based (hospital funded) positions are increasingly rare. Instead, there may be any range of seemingly complex models currently in practice: grant funded, production (RVU) based, quality benchmarking, internally funded positions (such as directorships, chairs, fellowship coordination), hospital system efforts (such as antimicrobial stewardship, infection control, and OPAT) – and any combination of these such that salaries are often patched together. A growing number of Pediatric ID physicians are also in hybrid positions, commonly hospitalist, ER/urgent care, even primary care. Others may be the shared pediatric ID physician among several hospitals in a given area.

Significant work is being done by both adult and pediatric ID societies regarding the value of the ID physician,3,4 the ramifications of which we hope will translate into some protection from these new compensation models that are emerging. I spoke with Dr. Julia Szymczak regarding her abstract presented as a platform at PAS this year, titled: "Beyond the RVU: Exploring the Value of a Cognitive Pediatric Subspecialty." She conducted interviews with key stakeholders, including hospital administrators, surgeons, subspecialists, and pediatric infectious disease physicians, at 5 different hospitals across the country to explore and understand the value of a pediatric infectious disease physician to a healthcare organization. Several domains of how we are valued were recognized. Unfortunately, many of these areas escape capture by current measures that administrators use to justify the finances needed to retain a pediatric infectious diseases physician (manuscript forthcoming).

We, as a group, know we are important. Papers have been written about the value ID physicians add to patient care and a health system5-8. Additionally, Szymczak et al. demonstrated that others know our value too9. Why are we struggling to translate value into sustainable positions and comparable salaries? That is a bit more nebulous to answer but one we wish to make progress toward. In the meantime, there are some actionable items now, several of which Dr. Szymczak captured in her study and have been discussed in recent literature and on the IDSA website, such as maximizing our billing and coding efforts, most of which are likely time based, to ensure that we don't miss out on giving ourselves value for the time we spend with patients9, 3. Thinking about creative ways to expand referral bases through telemedicine10 or contracting to offer phone consultations are also ongoing efforts.

Other interventions may require a system based approach: negotiate with our hospital administrators and local insurance providers regarding bundling of payments, or fund programs like OPAT via the surgical specialties that use it the most. We must be adept in the language of what hospital administrators want to hear (Triple Aim?! Hospital Strategic Plan?! I'll show you how our work meets these and more!). Advocating for increased hospital funded time to sustain system efforts like infection control and other programs may be helpful when we share with each other how we do this in our respective institutions and how successful (or unsuccessful) we have been.

And while we are doing this, I do think we must move away from the stigma that we are a "revenue losing" specialty by developing ways to better capture how much money we SAVED a hospital or health system. For example, the undocumented and uncompensated work that we often undertake includes curbside consults from our colleagues and phone calls from outside physicians and providers, recently highlighted by Dr. Paul Sax's blog11. Creating and validating tools to measure the time and activities we do to prevent a hospitalization or readmission or that could be handled through an outpatient visit will be extremely helpful. Personalizing system based efforts, such as the impact of hospital based guidelines or outbreak management and translating that into cost-savings may also be a worthy effort.

The RVU system is here at my institution. And while things may change in another few years when reimbursement strategies are overhauled yet again, this has been a valuable time for me to think about these issues, which will likely follow us through the years.

For now, in the blank box for clinical productivity goals on my annual review, I've written:

  • Know and understand the strategic plan and priorities for my institution
  • Work with coders to determine if I've been appropriately billing, and if not, improve on this
  • Begin to engage colleagues to better understand how others are faring at their respective institutions to see where value has been recognized.

I'll let you know how I fare in a year! -- Louise Vaz, MD, MPH


  1. Rochlin JM, Simon HK. Does fellowship pay: what is the long-term financial impact of subspecialty training in pediatrics? Pediatrics. 2011 Feb; 127(2):254-60.
  2. Castle VP, Gilsdorf JR. Assessing the value of pediatric consultation services as bundled payments evolve: infectious diseases as a model. J Pediatr. 2014 Oct;165(4):650-1
  3. Infectious Disease Society of American. Value of ID specialists' toolkit. Website: Accessed 6/14/2015.
  4. Gilsdorf, J. Presidents' Letter Accessed June 15, 2015.
  5. Fariñas MC1, Saravia G, Calvo-Montes J, et al. Adherence to recommendations by infectious disease consultants and its influence on outcomes of intravenous antibiotic-treated hospitalized patients. BMC Infect Dis. 2012 Nov 9;12:292.
  6. Honda H, Krauss MJ, Jones JC et al. The value of infectious diseases consultation in Staphylococcus aureus bacteremia. Am J Med. 2010 Jul;123(7):631-7.
  7. McQuillen D, Petrak R, Wasserman R et al. The Value of Infectious Diseases Specialists: Non–Patient Care Activities. Clin Infect Dis. 2008 47 (8): 1051-1063.
  8. Petrak RM, Sexton DJ, Butera ML, et al. The value of an infectious diseases specialist. Clin Infect Dis. 2003 Apr 15;36(8):1013-7.
  9. Szymczak J, Lee GM, Woods C et al. Beyond the RVU: Exploring the Value of a Cognitive Pediatric Subspecialty. Presented as Platform. Pediatric Academic Societies Meeting 2015, San Diego CA. April 25. Abstract No. 1180.8.
  10. Kahn, J. Virtual Visits — Confronting the Challenges of Telemedicine. N Engl J Med 2015; 372:1684-1685.
  11. Sax, P. Seriously, How much would you pay for a curbside consult? Accessed June 15 2015.

The Pediatric Infectious Diseases Society (PIDS) is proud to stand with more than 150 organizations and key stakeholders in making strong commitments to improving the appropriate use of antibiotics. Announced at today's White House Forum on Antibiotic Stewardship, the commitments highlight the importance of using antibiotics wisely to help slow the emergence of resistant bacteria, preserve the efficacy of existing antibiotics, and limit the spread of resistant infections.

Drug-resistant infections are responsible for at least 23,000 deaths and 2 million illnesses in the U.S. each year, according to the Centers for Disease Control and Prevention. Yet studies suggest that up to half of all antibiotic use in people, including children, is unnecessary or inappropriate, contributing to rising rates of resistance as effective treatment options for resistant infections dwindle.

"As a leading organization of physicians, scientists, and other professionals dedicated to treating and preventing infections in children, effective antibiotic stewardship has been a PIDS priority for several years," said PIDS President Janet R. Gilsdorf, MD, FPIDS. "We are thrilled to join with the other organizations and stakeholders at this forum today in making important commitments to improve the appropriate use of antibiotics."

Among these is continued support for the Annual International Pediatric Antimicrobial Stewardship Conference, jointly sponsored by PIDS and Children's Mercy Hospitals and Clinics in Kansas City, Missouri. Now in its sixth year, the conference will bring together medical professionals June 4-5 to discuss how to develop and maintain effective stewardship programs. Other PIDS commitments announced today include:

  • Supporting efforts to identify best practices for improving antibiotic use in the care of children in hospitals and outpatient settings.
  • Collaborating and partnering with other key organizations on provider education, the development of clinical practice guidelines, and other areas.
  • Supporting research on rapid diagnostics to improve antibiotic use and patient outcomes.
  • Advocating for the appropriate use of antibiotics in the agriculture industry.

A full list of PIDS commitments announced at the White House is available online:

"Antibiotic resistance is a serious and growing threat to public health and to our pediatric patients," said Jason Newland, MD, MEd, FPIDS, chair of the PIDS Pediatric Committee on Antimicrobial Stewardship and PIDS' representative at today's forum. "Using antibiotics wisely to preserve their effectiveness is a key part of the broader, multi-disciplinary approach we need to combat this problem. It will take all of us working together to meet this challenge."

A recognized leader in the field of antibiotic stewardship and another PIDS member also attending the forum, Theoklis Zaoutis, MD, MSCE, FPIDS, noted the high stakes involved. "Antibiotics are a precious, lifesaving, and limited resource," Dr. Zaoutis said. "Unless we do more to use this resource judiciously and take additional actions to address resistance in a comprehensive way, our patients' lives are at risk from these resistant infections."


About PIDS

PIDS membership encompasses leaders across the global medical, scientific, and public health spectrum, including clinical care, advocacy, academics, government, and the pharmaceutical industry. From fellowship training to continuing medical education, research, regulatory issues and guideline development, PIDS members are the core professionals advocating for the improved health of children with infectious diseases both nationally and around the world, participating in critical public health and medical professional advisory committees that determine the treatment and prevention of infectious diseases, immunization practices in children, and the education of pediatricians. For more information, including links to additional reliable sources of information about antibiotic resistance, visit

"Freedom from infections for all children through excellent clinical care, research, education, and advocacy"

This is the vision of the Pediatric Infectious Diseases Society, built on the guiding principles of our Founding Fathers (and Mothers). To this end, the Society has realized significant accomplishments over the past two years under David Kimberlin's outstanding and insightful leadership.

So, where do we go from here?

In the past month, the Society has reviewed the priorities of the members as revealed in the most recent Needs Assessment survey. Based on those results, we have established five pillars upon which to build the activities of the Society over the next two years and, through the Strategic Planning exercise during the recent PAS meeting, developed strategies to strengthen these pillars.

Pillar 1: Value of Infectious Diseases to Hospital Systems

As health care in the United States moves from fee-for-service to contract-based reimbursement for clinical services, the value of our expertise in meeting the goals of hospital systems, in both financial and clinical outcomes, will be paramount. Led by Dr. Julia Szymczak, a post-doctoral fellow in medical sociology, the Society's Value of Pediatric ID as a Subspecialty subcommittee has completed a qualitative, focus-group based study of five pediatric inpatient units and will publish the results soon. In addition, the Journal of the Pediatric Infectious Diseases Society will soon publish a systematic review of pediatric antibiotic stewardship programs, accompanied by an editorial, and Dr. Theo Zaoutis' group is conducting a quantitative study of the outcomes of patients with and without PID consultations. Materials from these efforts will be available to members as they educate their health systems about the value of our clinical services.

Pillar 2: Recruitment of Future ID Pediatricians

This was not a good year for the ID match, either for adult or pediatric training programs. Only 41% of PID participating training programs and 45% of certified positions in PID filled. The Needs Assessment survey identified three priorities in meeting this challenge: (a) Increase the awareness of the value of PID consultations, (b) Increase efforts to achieve compensation equal to other subspecialties, which is directly related to (a), and (c) Increase awareness of career choices for PID trainees. Over the next two years, our Society will work with IDSA to better understand and reverse the recent trend away from infectious diseases among young physicians and will develop materials for training programs to educate their students, residents, and ID trainees about the wide variety of professional opportunities for pediatricians with ID expertise.

Pillar 3: Training and Guidance for PID Fellows

Our fellows are our future and, since its inception, the Society has been devoted to facilitating the education of new ID pediatricians. The top four priorities identified in the Needs Assessment survey regarding fellowship training are: (a) Develop training opportunities for the care of the immunocompromised host, (b) Develop training opportunities related to antibiotic stewardship, (c) Enrich research opportunities, and (d) Provide career guidance. The Society will meet these priorities by continuing to support/endorse courses on transplant infectious disease, HIV pediatric disease, and related topics in conjunction with the St. Jude/PIDS Pediatric Infectious Diseases Research Conference and the annual International Pediatric Antibiotic Stewardship Conference held at Children's Mercy Hospital in Kansas City, Missouri. In addition, the Society and its Foundation will continue to provide research awards to promising fellows and to support the St. Jude/PIDS Pediatric Infectious Diseases Research Conference in its highly valuable career development sessions.

Pillar 4: Research Activities Related to Pediatric Infectious Diseases

Developing new understanding of microbes and their disease-causing processes as well as evaluating the most effective means for diagnosing, treating, and preventing infections has been a cornerstone of the Society since its very beginnings. And yet, lack of research funding was identified in the Needs Assessment survey as the third greatest concern among our members. Almost 40% of respondents felt Society resources should be devoted to identifying key national research priorities in PID and lobbying for federal action and funding, which is a major activity of the Research Affairs Committee. Further, almost 80% of respondents indicated they are interested in participating in PID-related clinical multicenter studies. The future is bright for our members in these activities and the Research Affairs Committee will assist in identifying and coordinating such opportunities.

Pillar 5: Engagement of New and Established PIDS Members

Our Society is rich with members who generously contribute their time and expertise to its many activities. And yet, the Needs Assessment survey revealed that only 55% of respondents feel engaged with PIDS activities. This, actually, isn't bad for a professional society, but we can do better. Over the next two years, the Society will continue to encourage its members to participate in our important activities. What can you do? For starters:

  1. Maintain your membership by paying the annual PIDS dues
  2. Volunteer for committee membership. If your first request cannot be honored, reapply next year. And the next.
  3. Respond to the next Needs Assessment survey so we know what is most important to you.
  4. Attend meetings sponsored by PIDS
  5. Participate in PAS and IDWeek programs sponsored by the Society
  6. Read, promote, and submit your best scientific work to the Journal of the Pediatric Infectious Diseases Society
  7. Serve as an enthusiastic role model for undergrads, medical students, and residents as they refine their career choices
  8. Respond to calls for congressional support letters sent by IDSA and the AAP on issues related to PID. Congressional aides tell us these really matter.

With great enthusiasm, I look forward to working with you as, together, we shepherd our specialty and our Society solidly into the future.

Janet R. Gilsdorf, MD, FPIDS
President, Pediatric Infectious Diseases Society

Out with the old, and in with the new! The wheel of the academic calendar is about to turn once again, with graduations planned for those fellows finishing training and taking exciting new faculty roles at home or at other institutions, and preparations made for orientation of shiny new fellows in one month's time. This June every Pediatric Infectious Diseases program is required to report on its fellows for the second time using the ACGME milestones, a set of evaluation tools intended to provide finer detail in assessing each trainee's progress toward competence and independent practice. As we bless the abilities of the outgoing fellows and the next wave of fellows prepares to embark on the intellectual adventure that is fellowship, it seems a perfect time to ruminate on the ever-shifting landscape of Pediatric Infectious Diseases.

We don't often think about generational differences in our training environment, but they are certainly there. The tools, attitude, and practice of the emeritus professor will undoubtedly differ from those of the sprightly new fellow. Many of those retiring from practice are baby boomers; many of those starting training are millennials. What are we losing as one generation moves on, and what are we gaining as the other enters our field? How do these changes specifically affect us in Infectious Diseases?

Baby boomers are traditionally described as having a very strong work ethic and going the extra mile, being loyal to their employers, building on consensus leadership, and being oriented toward service and the larger mission of their work. As they retire, we are losing master clinicians whose dedication and ideas have markedly improved our field and advanced scientific understanding over their careers.

These losses are balanced against what we gain from our new trainees. Millennials have grown up in a world of big data and instant gratification, they expect respect, and they are the most highly educated generation to date. These traits – which could be seen as negative – may stand to improve our field yet further. Millennials are focused on making a contribution with their efforts and are goal-oriented. Their facility with technology allows them to multi-task better than the rest of us. They love continuous feedback, and they find new, entrepreneurial solutions to problems. For example, an Orthopedics resident here at the University of Washington who knew how to write computer code decided to create a program for collecting ACGME milestone evaluations that could be easily accessed on his attendings' smartphones, and is now sharing his program with other specialties. Through their ingenuity, the millennials can even make mundane required reporting feel entertaining. Millennials want variety and fun at work, they prize diversity and work-life balance, and they want to participate in a global community. Doesn't sound so bad, does it?

As we go to upload our ACGME milestones reports, we should ask our trainees how to use, gather, display, and understand the data we've generated. The milestones really are a new experiment in how best to train physicians, and we would all do well to enlist the help of our clever trainees in figuring out how to collect and utilize them best. And while we lose the retiring experts who provide our expert consensus around clinical care, we can use this as an opportunity to move away from older, bad habits that are hard to break (such as use of IV antibiotics when oral ones will do) and instead embrace the newest in evidence-based medicine that the millennials may end up finding and teaching us. After all, at the rate articles are published in PubMed, if you read just one new journal article a day in 2014, you would be about 3,200 years behind in your reading at the end of the year. We are inundated with data, from a fellow's progress in the ACGME milestones to the trend in a patient's C-reactive protein; keeping up with medicine is difficult today, but the millennials are poised to make it easier. If we can be open-minded in our conceptions of Infectious Diseases careers, there is no doubt that the millennials will harness their skills and the current abundance of data to combat infections in ways we never imagined. - Matthew Kronman, MD

Pediatricians like antibiotics. Of the top ten medications prescribed to children, five of them are antibiotics accounting for over a quarter of outpatient prescriptions in children [1]. On average, there are 1365 prescriptions of antibiotics written per 1000 children less than 2 years of age [2]. A main driver for the large number of antibiotic prescriptions is the perception that oral antibiotics are largely safe drugs. The prevailing thought is that there is little downside of antibiotic usage due to their large therapeutic window. Of course, for those of us who care for children who require long courses of antibiotics, we know that these are not benign drugs. We've all seen the complications of prolonged therapy, even oral therapy, including allergies, neutropenia, hepatotoxicity, Clostridium difficile, and the development of antibiotic resistance. However, there is a paucity of data to confirm the dangers of prolonged oral antibiotics in children. In the current issue of the Journal of the Pediatric Infectious Diseases Society, Olson et al aim to determine the rate of adverse events from both parenteral and oral antibiotic use [3].

There has recently been increased scrutiny into the practice of long-term intravenous antibiotic therapy. The complication rate of antibiotics administered via peripherally-inserted central catheters (PICC lines) has been documented to be as high as 30% [4]. Because of this, there has been a push for early transition from intravenous to oral antibiotics in treating conditions that require prolonged antibiotics such as osteomyelitis [5]. The discussion is often framed as getting the patient off the more dangerous IV form of antibiotics and transitioning to the "safe" oral formulation. Intrinsic to this discussion is the assumption is that there are few risks to prolonged oral antibiotics, which may not be the case.

In this retrospective cohort study, Olson and colleagues reviewed charts of all patients seen in the Pediatric Infectious Diseases clinic at their tertiary care center who had received more than 14 days of antimicrobial therapy. Although they documented a lower catheter-related adverse event rate than others (13%), they reported a 31.9% overall adverse event rate for long-term antibiotic usage with similar rates between intravenous and oral antibiotic courses. Serious adverse events were seen more commonly in intravenous antibiotic usage but still occurred in 7.8% of patients receiving oral antibiotics. These included allergic reactions, neutropenia, renal, and liver abnormalities. Most striking was that 31.1% of reported adverse events were deemed severe enough to result in a change in medication. These data support the practice of close follow-up of all children receiving prolonged antimicrobial therapy regardless of whether it is administered via central catheters or by mouth.

Unfortunately, there are likely a large number of children who are discharged on prolonged antibiotics who may never be seen by an infectious diseases specialist and who may not have adequate follow up by other providers in a timely fashion. Given the high rate of adverse effects, this may lead to premature discontinuation or intermittent usage of antibiotic therapy, which could lead to treatment failure or the development of antimicrobial resistance. Although in this situation we cannot directly influence the care of children we do not consult on, we can continue to communicate to colleagues that antimicrobial treatment, even oral antibiotics, require a constant evaluation of the risks and benefits of continued therapy.

"Give enough but not too much. And we'd be happy to follow that patient in Peds ID clinic." -- David K. Hong, MD


  1. Chai G, Governale L, McMahon AW, Trinidad JP, Staffa J, Murphy D. Trends of outpatient prescription drug utilization in US children, 2002-2010. Pediatrics. 2012;130(1):23-31. PubMed PMID: 22711728.
  2. Hicks LA, Taylor TH, Jr., Hunkler RJ. U.S. outpatient antibiotic prescribing, 2010. N Engl J Med. 2013;368(15):1461-2. PubMed PMID: 23574140.
  3. Olson SC, Smith S, Weissman SJ, Kronman MP. Adverse Events in Pediatric Patients Receiving Long-Term Outpatient Antimicrobials. Journal of the Pediatric Infectious Diseases Society. 2015;4(2):119-25.
  4. Barrier A, Williams DJ, Connelly M, Creech CB. Frequency of peripherally inserted central catheter complications in children. Pediatr Infect Dis J. 2012;31(5):519-21. PubMed PMID: 22189533. Pubmed Central PMCID: 3329567.
  5. Keren R, Shah SS, Srivastava R, et al. Comparative effectiveness of intravenous vs oral antibiotics for postdischarge treatment of acute osteomyelitis in children. JAMA Pediatr. 2015;169(2):120-8. PubMed PMID: 25506733.

There is a vast crevasse between what healthcare workers (HCWs) perceive to be the problem and what they will do to overcome it.

This is particularly pronounced in the field of infection control. To give but one example, 44% of cases that occurred during the outbreak of severe acute respiratory syndrome (SARS) in 2003, despite the implementation of SARS-specific infection control directives, involved HCWs. When 15 HCWs of those affected were interviewed, eight were aware of a breach in infection control precautions, only nine reported receiving formal infection control training, 13 were unsure of how to properly don and doff personal protective equipment (PPE), and six reused items that had been potentially contaminated by a SARS patient.

The reuse of items after exposure to a SARS patient, the inconsistent use of PPE, and the awareness of half of the interviewed HCWs of a breach in infection control precautions, reflect the ongoing challenges of enforcing infection control. The focus of Fierro et al's publication in the most recent issue of JPIDS explored exactly why HCWs followed infection control and prevention guidelines or not. In the study, the authors surveyed several hundred HCW in the ambulatory setting regarding barriers to use of PPE when pertussis is suspected. Only 70% of clinical HCWs reported mostly or always wearing PPE when caring for a patient with suspected pertussis, while <30% reported wearing PPE for a patient with any respiratory symptoms.

Interestingly, HCWs identified three factors that were independently associated with PPE use: perceived availability of PPE (adjusted OR 5.41), knowledge and skills to improve PPE use (adjusted OR 4.62), and personal agency (adjusted OR 3.18). HCWs felt they would be 5.4 times more likely use PPE if masks were more available near the patient's exam room. So how is it that, when the authors placed masks in more accessible locations to increase the availability and use of PPE, that there was no substantial change in usage?

Perceived availability, ability and personal agency remained just that, a perception. This correlates with the HCW's belief that improving their own use of PPE was nearly a nonissue (adjusted OR 0.16). Like those who were aware of a breach in wearing PPE or with other infection control measures, HCWs did not allow their awareness of the precautions to lead to adopting them. Perhaps what the SARS case series demonstrates is that, even when battling an infectious pathogen that led to 774 fatalities worldwide, the implementation of infection control precautions in the face of severe and potentially fatal illness is still not enough to change behavior. Fierro et al. demonstrates this similarly, in the context of resurging pertussis epidemics across the country that place the youngest and vulnerable among us at most risk. We may have to rely on more than belief in one's ability and personal agency to create a sea change in the daily aspects of our practice. - Pui-Ying Iroh Tam, MD


Ofner-Agostini et al. Cluster of cases of severe acute respiratory syndrome among Toronto healthcare workers after implementation of infection control precautions: a case series. Infect Control Hosp Epidemiol 2006 May;27(5):473-8.

Fierro et al. Barriers to the use of PPE to prevent pertussis exposures in a pediatric primary care network. J Pediatr Infect Dis Soc 2015;4(1):49-56.

Written by: Christina Gagliardo, MD, FAAP

Global Public Health Intelligence Network (GPHIN)
Google Flu Trends

These are a few web-based systems which have contributed to technological improvements in surveillance capacity for significant public health events such as infectious disease outbreaks. These entities collect information and perform syndrome surveillance on specific diseases drawing from sources such as web-based queries, systems such as community-health based reporting with mobile phones, social media, and local news. When used in combination, detection of diseases and outbreaks is more timely and sometimes more sensitive than traditional surveillance systems (1-4). Examples include the Ebola outbreak starting in 2014 and several polio outbreaks in 2013 and 2014 where digital reports generated through these informal surveillance channels often preceded official reports (such as by WHO). For polio, digital surveillance reports were available 14.6 days (range 0-40 days) earlier than official WHO reports (4).

Another online surveillance tool, Google Flu Trends (GFT), was launched in 2008 and was intended to supplement traditional surveillance systems such as that done by CDC to monitor influenza. GFT analyzed Google search queries of influenza-like illness and symptoms and were able to improve early detection of influenza outbreaks one to two weeks ahead of CDC reports. GFT worked well to predict influenza outbreaks in the 2007-2008 flu season as well as during the 2009 H1N1 outbreak (5). In later years, however, it was noted that GFT grossly overestimated flu prevalence and predicted double the amount of doctor's visits than CDC surveillance (6-8). A proposed solution was to combine CDC data with GFT-derived information that was "recalibrated" to be more reliable, with the thought that when used in combination, performance would be better than GFT or CDC alone. This is in line with the original proposed intention of GFT: to be used as a "'complementary signal', rather than a stand-alone forecasting tool" (9).

The exponential increase in the use of social media, such as Twitter, provides another potential opportunity to perform public health surveillance and create predictive models. Once group successfully used Twitter data to show that CDC influenza-like illness rates correlated to the rate of Tweets of influenza infection, and predicted influenza two to four weeks sooner(10). The New York City Department of Health and Mental Hygiene validated their model and showed a strong parallel to local influenza activity as well (11).

A leading researcher in the field of digital epidemiology is Marcel Salathé, PhD. His study showed a correlation between CDC-estimated vaccination rates by region and geo-spatial vaccine sentiments as expressed on Twitter (12). When simulating an infectious disease outbreak, he showed that grouped negative sentiments about vaccines lead to clusters of unprotected people, which increased the likelihood of an outbreak in that area.

Analyzing big data generated through social media to perform "digital epidemiology" and surveillance continues to be enhanced and developed. Eventually it may be a reliable tool which we can easily access to perform infectious disease surveillance on a large scale and more relevant to our everyday practice, on the local level. It is an emerging field with huge amounts of untapped utility and the potential for collaboration between science, medicine, public health, and technology.


  1. Hulth A, Gustaf R, Annika L. Web queries as a source for syndromic surveillance. PLoS One 2009; 4: e4378.
  2. Freifeld CC, Chunara R, Mekaru SR, et al. Participatory epidemiology: use of mobile phones for community-based health reporting. PLoS Med 2010; 7: e1000376.
  3. Barboza P, Vaillant L, Le Strat Y, et al. Factors influencing performance of internet-based biosurveillance systems used in epidemic intelligence for early detection of infectious diseases outbreaks. PLoS One 2014;9: e90536.
  4. Anema A, Kluberg S, Wilson K, Hogg R, Khan K, Hay S, Tatem A, Brownstein J. Digital surveillance for enhanced detection and response to outbreaks. Vol 14 November 2014
  5. Ginsberg J, Mohebbi MH, Patel RS, Brammer L, et al. Detecting influenza epidemics using search engine query data. Nature. 2009 Feb 19;457(7232):1012-4. doi: 10.1038/nature07634.
  6. Lazer, David; Kennedy, Ryan; King, Gary; Vespignani, Alessandro (14 March 2014). "The Parable of Google Flu: Traps in Big Data Analysis". Science 343 (6176): 1203–1205. doi:10.1126/science.1248506.
  7. Lazer, David, Ryan Kennedy, Gary King, and Alessandro Vespignani. 2014. "Google Flu Trends Still Appears Sick: an Evaluation of the 2013‐2014 Flu Season". Copy at 
  8. Butler, Declan (13 February 2013). "When Google got flu wrong". Nature 494: 155–156. doi:10.1038/494155a.
  9. Lohr S. Google Flu Trends: The Limits of Big Data. 3/28/14. NY Times. 
  10. Paul MJ, Dredze M, Broniatowski D. Twitter Improves Influenza Forecasting. PLOS Currents Outbreaks. 2014 Oct 28. Edition 1. doi: 10.1371/currents.outbreaks.90b9ed0f59bae4ccaa683a39865d9117
  11. Sills J. Twitter: Big Data opportunities. Science, Letters. 
  12. Salathe´ M, Khandelwal S (2011) Assessing Vaccination Sentiments with Online Social Media: Implications for Infectious Disease Dynamics and Control. PLoS Comput Biol 7(10): e1002199. doi:10.1371/journal.pcbi.1002199
  13. Costello, V. Researchers Changing the Way We Respond to Epidemics with Wikipedia and Twitter. PLoS Blogs. Jan 2015. 


With the chaos of interviews, rank lists, and Match Day complete, I have found myself reflecting on our successful resident recruitment season. In the nearly 120 interviews I conducted, I was struck by a few things. First, pediatrics has attracted some great medical students – smart, motivated, and well-rounded. Secondly, I was surprised by the number of applicants who had already decided on a subspecialty, or at least narrowed it down to 2 or 3. Finally, I was saddened by the paucity of students who had an interest in infectious diseases.

I was left pondering 2 questions: Why do these great applicants not include ID in their list of top career contenders? Are we targeting the wrong group with our recruitment efforts?

Let's face it, pediatric ID isn't as outwardly "sexy" as higher profile fields like oncology or cardiology. There aren't too many fundraisers for kids with infections and ID isn't ranked as a pediatric specialty in U.S. News and World Reports. And while I don't expect to draw the adrenaline-junkies away from the faster-paced procedure-based specialties, I heard more interest in other non-procedure based fields like endocrinology or genetics than ID. It's also true that pediatric ID isn't compensated as well as some of these higher profile or procedure-based specialties, but that answer seems too simplistic. Students interested in pediatrics are generally not motivated by money, so what has caused this dearth in interest?

One factor that is potentially missing is exposure. Based on studies analyzing the timing of post-residency career choices, it seems early exposure is key to sparking interest. For many pediatricians, their choice of career path is decided during medical school or very early in residency. In a survey-based study, Dattner and Ozuah reported 50% of PGY-1 pediatric residents had already decided on a career path. Moreover, Freed and colleagues reported over a third of pediatric subspecialists decided to pursue subspecialty training prior to even starting residency. However, our fellowship recruitment efforts tend to focus on residents, not students. Many medical students have limited clinical experience in pediatric ID. While they may get routine and repeated exposure to other pediatric subspecialties, we in ID are often limited to interacting with students only briefly during lectures or while making rounds on the consult service. So in order to ensure a steady stream of qualified physicians in pediatric ID, would we be better served by equally concentrating attention on medical students AND residents early in training?

Finally, interest in a specialty or patient population is typically the most important factor influencing a postresidency career. While we can't force interest, we can educate trainees about the diverse populations and career paths within pediatric ID. By exposing students to the breadth of clinical cases and opportunities, we can perhaps help foment greater interest in our field. We also cannot underestimate the positive influence of role models. Studies in many medical fields have shown that working with a highly (or poorly) rated faculty member influences students' likelihood of choosing that specialty. So we in the PIDS community must strive to cultivate interest, provide mentorship, and recruit qualified pediatricians early and often throughout the medical education journey. By: Rebecca Wallihan, MD


Dattner, Laura, and P. Ozuah. "Career Decision-Making among Pediatric Residents." Medical Education Online North America 10 (2005): 1-6.

Freed, Gary L., et al. "Recently trained pediatric subspecialists: perspectives on training and scope of practice." Pediatrics 123.Supplement 1 (2009): S44-S49.

In the March 2015 issue of the Journal of the Pediatric Infectious Disease Society, Le Doare and colleagues report the findings of their systematic review of antibiotic resistance rates in gram-negative bacteria (GNB) in children with sepsis living in resource-poor countries. A systematic review of PubMed, Embase, and World Health Organization (WHO) databases was performed for studies on children with sepsis living in low- and middle-income countries. Ultimately 30 studies were included in the review, comprising 71,326 children. 7,056 (13.9%) of those had positive blood cultures and GNB's were isolated in 4710 (66.8%) of those. In general, antibiotic resistance to WHO first-line agents was widespread. In neonates, Klebsiella pneumoniae was the most common pathogen; in Asia, its median resistance to ampicillin was 94%, to cephalosporins 84%; and in Africa, 100% and 50% respectively. Rates for other enterobacteriaceae in the neonatal population were similar. In children, Salmonella was the most common organism and MDR Salmonella (resistant to amoxicillin, co-trimoxazole, and chloramphenicol) was widespread, though resistance rates varied wildly by region: 30% in Asia and 75% in Africa. The authors conclude that there is a need for better antimicrobial resistance (AMR) surveillance, which should then shape improved WHO guidelines that acknowledge prevalent resistance to previous first-line agents, together with improved stewardship and infection control.


We are all acutely aware of the rising burden of antimicrobial resistance and morbidity and mortality caused by it. But the now-infamous 2013 CDC threat report [CDC 2013], outlining 23,000 deaths and 2,000,000 episodes of morbidity attributable to resistant infections, only applies to the United States, and is not based on pediatric-specific data. When we turn to look at the rest of the world, the burden of pediatric bacterial disease overall and that due to resistant organisms specifically is astounding. This study provides a much-needed examination of the epidemiologic characteristics of GNB sepsis and the resistance patterns of the causative organisms in resource-poor countries. As the authors note, bacteremia remains a leading cause of death in children and neonates worldwide, with an estimated 6% of neonatal deaths and 14% of all childhood deaths, making this a potent area for study.

There are two areas of their review worth examining in greater detail, the first of which is the sheer degree of resistance found. For those of us practicing pediatrics in the United States, while antimicrobial resistance is a problem, it is currently a surmountable one. A recent study by Pranita Tamma and colleagues [Tamma et al. 2013] found susceptibility rates for Klebsiella pneumoniae of 94% to 3rd-generation cephalosporins and 93% to gentamicin. But as the present study shows, the developing world is altogether different, with data there quite concerning. They found resistance rates that were of a similar magnitude to our susceptibility rates here. In Asia only 16% of K. pneumoniae isolates were susceptible to 3rd-generation cephalosporins and in Africa 50% were. Gentamicin susceptibility was similarly low, 32% in Asia and 46% in Africa. These particular agents are significant, as the WHO guidelines for neonatal and pediatric sepsis are largely similar to those in the United States, with a recommendation for ampicillin and gentamicin/3rd-gen cephalosporin or a 3rd-generation cephalosporin alone, depending on age. Currently, with those guidelines, 84% of the children with K. pneumoniae sepsis studied in this review would fail empiric therapy. If this data accurately reflects not just the populations of the papers analyzed, but indeed the larger population in the countries studied, current WHO guidelines may leave anywhere from 50-85% of patients with GNB infections completely untreated.

The second significant finding of this study is the high variability in resistance seen among Salmonella isolates. In particular, the variability of MDR isolates is concerning. While the rates they report by region were 30% for Asia and Southeast Asia and 75% for Africa and the Middle East, when examined by country, anywhere from 30% to 100% of isolates were MDR. And this variability is an area where the WHO guidelines again unintentionally leave a hole: the WHO guidelines of first-line use of chloramphenicol will have wildly varied treatment efficacy among the different countries. Individual countries could in theory make their own treatment guidelines but in practice the nature of their designation as resource-poor makes this unrealistic, leaving wide potential for ineffective treatment of what the authors found was an extremely common organism. Moreover, the resistance mechanism is plasmid-mediated via the incH1 plasmid, at least in non-typhoidal strains. As we have seen with other newer emerging resistance mechanisms such as the NDM-1 New Delhi metalloprotease, spread of an MDR GNB is as easy as a plane flight and from there plasmids can jump promiscuously. So while resistance rates are varied between regions and countries currently, given time this resistance will only spread further.

As the authors themselves note, both the high rates of resistance and the high rates of variability require better monitoring to validate data across a more representative sample of countries and locales within those countries (nearly all the papers they reviewed were based on tertiary-care centers in larger cities). At a minimum this data would be used to implement new empiric treatment guidelines that more accurately reflect the realities of current resistance spectra. But as we are beginning to realize more here at home, some of the most cost-effective changes these countries can make are in improving infection control guidelines and implementing comprehensive antimicrobial stewardship. New or better drugs just may not be a reality and so making better, smarter use of the ones we do have could make all the difference. By: Saul Hymes, MD


  1. Le Doare K, Bielicki J, Heath PT, Sharland M. Systematic Review of Antibiotic Resistance Rates Among Gram-Negative Bacteria in Children With Sepsis in Resource-Limited Countries. J Ped Infect Dis (2015) 4(1):11-20.
  2. Antibiotic Resistance Threats in the United States, 2013. The Centers for Disease Control and Prevention, 2013. 
  3. Tamma PD, Robinson GL, Gerber JS, Newland, JG, DeLisle, CM, Zaoutis, TE, Milstone, AM. Pediatric Antimicrobial Susceptibility Trends across the United States. Infection Control (2013) 34(12): 1244 – 1251.

Last January, I had the opportunity to share some thoughts on PIDS' role in combating vaccine-preventable diseases, focusing on vaccine advocacy, innovative studies of pathogenesis, high-quality epidemiologic studies, and rigorous clinical trials. Now, one year later, we are experiencing a measles outbreak in the US that has affected over 100 people in 14 states, most of which are linked to an exposure at a California amusement park. As the outbreak unfolds, we are reminded of the cardinal symptoms of measles, a disease that many practicing physicians have never seen; the efficient transmission of the virus to unvaccinated individuals; and the importance of PIDS' ongoing education and vaccine advocacy efforts.

As recently as the 1950s, measles was one of the most common childhood infections in the US. On average, about half a million cases, 50,000 hospitalizations, 1,000 cases of chronic disability, and 500 deaths were reported each year; however, due to underreporting, it is estimated that as many as 4 million cases occurred annually. In many ways, measles is a typical respiratory illness, leading to fever, cough, coryza, conjunctivitis, and malaise. Because of this, and because of the fleeting nature of pathognomonic Koplik spots, we must maintain a reasonably high index of suspicion, particularly in our unvaccinated patients, in order to identify measles cases promptly. When measles is suspected, providers should evaluate measles-specific serum IgM antibody and measles RNA by PCR from both the oropharynx and the urine.

The timely diagnosis of a case of measles is of critical importance, since a single measles patient will infect approximately 15 others in the absence of pre-existing immunity (R0~15), making measles the most easily transmitted virus on the planet (for comparison, smallpox R0~5, Influenza R0~3). Moreover, 90% of non-immune individuals will develop measles infection following close contact with an infected individual. Fortunately, the MMR vaccine is remarkably effective (~95% after one dose and 98-99% after 2 doses) in generating life-long, protective immunity. The MMR vaccine is also effective if administered within 72 hours of measles exposure and is recommended for infants as young as 6 months of age if exposure is likely (e.g., travel to an endemic area).

This effectiveness of the MMR vaccine in preventing measles infection is the foundation of measles eradication efforts, which have been highly successful in many parts of the globe. PIDS members continue to play key roles in this effort, leading clinical trials, conducting global epidemiology studies, and informing public policy decisions. It is now time, through our vaccine advocacy committee, training programs, and local media markets to redouble our efforts in reassuring parents and providers about the safety of MMR vaccine and the importance of vaccine coverage (>93% coverage is required in a community to disrupt transmission). For more information about the current outbreak and for general talking points about measles, please visit the PIDS website (

The eradication of measles has been a daunting task; unfortunately, the eradication of misinformation and mistrust may be even more so. Allowing measles to resurface essentially turns back the pediatric clock by several decades, reintroducing morbidity and mortality that are a distant memory. Our job, as a society and as individual members, is to provide clear, trustworthy information to our trainees, our patients, and the general public in order to ensure these preventable outbreaks do not become the new epidemiologic norm. - by Buddy Creech, MD, MPH, FPIDS

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