AAP Behind the Scenes 2020 (Part 1): Pandemic Monitoring

Currently I am vice chair for the section of nutrition at the Georgia Chapter of the American Academy of Pediatrics; Dr. Tanya Hofmekler is now chair of the section.  I recently attended a Board Meeting which received reports from a number of committees.  One of the presentations from Dr. Evan Anderson (infectious disease specialist), provided an update on the coronavirus, the flu, and other emerging infections.

Key Points:

  • Coronavirus appears to be more contagious than the flu but less contagious than many other infections like measles
  • CDC has website which is update for the coronavirus which is updated frequently:  2019 Novel Coronavirus (2019-nCoV) Situation Summary
  • This is a bad year for the flu (see “red line” on last two slides).  The number of hospitalizations/mortality in young children (0-4) is increased compared to previous years, though the number of cases has been higher in previous years
  • There is now an FDA-approved Ebola vaccine
  • A single case of measles can cost $50,000 for public health to respond; direct medical costs could be much higher

Slide above was accurate on 2/8/20

 

 

Satire from The Onion

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Real-World Vedolizumab: Better Than Expected

Two recent studies indicate that vedolizumab is performing better than expected in the “real world.”

  • JL Koliani-Pace et al. Inflamm Bowel Dis 2019; 25: 1854-61
  • DM Faleck et al. Clin Gastroenterol Hepatol 2019; 17: 2497-2505.

In the first study, the researchers used 2 data sets (VICTORY cohort, n=1087, & the Truven cohort, n=2574)  to compare vedolizumab in two separate eras; the early era was May 2014-June 2015  and the later era was July 2015-June 2017.

Key findings:

  • Patients with Crohn’s disease (CD) in the VICTORY cohort during the second era had better clinical remission rates: 40% vs 31% and better mucosal healing rates 58% vs 42%
  • Later era patients with ulcerative colitis (UC) in the Truven database had lower rates of IBD-related hospitalization (22.4% vs. 9.6%) and surgery (17.2% vs. 9.4%)
  • In the later era, patients were more likely to be biologic naive.

This study indicates that, overall, patients treated in the first era were likely more sick and less likely to respond to vedolizumab.  The authors’ note that this could be a ‘warehouse effect’ whereby “patients treated within the first year of a drug’s approval are likely representative of a select group of high-risk patients who are refractory to currently available therapies and are being warehoused on ineffective and undesirable therapies (ie. chronic steroid) to bridge them through until a promising agent is approved by the FDA.”

In the second study, the authors retrospectively examined 650 patients with CD and 437 with UC who were treated between 2014-16.  Patients who had a more recent diagnosis of CD (≤2 years) fared better than those with more long-standing disease.

Key findings:

  • Early-stage CD vs. later-stage CD clinical remission rates: 38% vs 23%
  • Early-stage CD vs. later-stage CD with corticosteroid-free remission: 43% vs 14%
  • Early-stage CD vs. later-stage CD with endoscopic remission: 29% vs. 13%
  • UC disease duration did not associate with response to vedolizumab

My take: Taken together, these studies indicate that vedolizumab in the real world may outperform the results of the landmark studies which helped garner FDA approval.  In patients who are less sick and have not been considered refractory to multiple treatments, response rates to vedolizumab are higher.

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More on the Flu -5 Reasons for the Flu Shot

Last year’s deadly flu was likely due in part due to a low rate of vaccination.

From NPR: 5 Reasons Why You Need the Flu Shot

Last year “more than 80,000 people died from flu-related illnesses in the U.S. — the highest death toll in more than 40 years.” So 5 reasons to get your shot:

1. You are vulnerable.

People 65 and older are at higher risk of flu-related complications, but the flu can knock young, healthy people off their feet, too. It does every year.

2. Getting a flu shot is your civic duty.

“Nobody wants to be the dreaded spreader,” says Schaffner. But everybody gets the flu from somebody else.

3. You can still get the flu, but you won’t be as sick.

After last winter’s severe season, some people are skeptical. They say: “I got the flu shot, but I still caught the flu.”

4. Pregnant women who get the flu shot protect their babies from flu.

Women who are pregnant should be vaccinated to protect themselves. The vaccine also offers protection after babies are born

5. You cannot get flu from the flu vaccine.

It’s still a common misperception: the idea that you can get the flu from the flu shot.

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Almost Everybody Needs Flu Shot –IBD Patients at Higher Risk

Link: CDC Recommendations for Influenza Vaccination

  • Routine annual influenza vaccination is recommended for all persons aged ≥6 months who do not have contraindications.
  • Vaccination should be offered by end of October; however, vaccination should continue to be offered as long as influenza viruses are circulating and unexpired vaccine is available.

 

Not Preparing for the Next Pandemic

A terrific commentary (Bill Gates, NEJM 2018; 378: 2057-60) explains how we are NOT preparing for the next pandemic and what we should be doing and why.

Key points:

  • There has been incredible progress in many areas of global health and infectious diseases.  In fact, “child mortality has decreased by more than 50% since 1990.”  HIV is no longer “a certain death sentence” and there has been progress with malaria.
  • Yet, “there is a significant probability that a large and lethal modern-day pandemic will occur in our lifetime.”  Some recent events have alerted us to this risk, including swine flu in 2009, Ebola in 2014 as well as recent MERS (Middle East respiratory syndrome) and SARS (severe acute respiratory syndrome).
  • “We need better tools, an early detection system, and a global response system.”
  • “A simulation by the Institute for Disease Modeling shows what would happen if a highly contagious and lethal airborne pathogen, like the 1918 influenza, were to appear today.  Nearly 33 million people worldwide would die in just 6 months.” (see below)
  • Vaccine development holds some promise to protect against many pathogens.  One step to help with vaccines has been a public-private venture, Coalition for Epidemic Preparedness Innovations (CEPI).
  • Vaccines alone are not enough as they take time to stimulate immunity and often not enough people receive them.  “So we need to invest in other approaches, such as antiviral drugs and antibody therapies that can be stockpiled.”

My take (borrowed): “”If it were a military weapon [threat], the response would be to de everything possible to develop countermeasures.  In the case of biologic threats, that sense of urgency is lacking.  But the world needs to prepare for pandemics in the same serious way.”

American Academy of Pediatrics: Georgia Chapter Governing Board Meeting

As usual, I learned a great deal from our recent governing board meeting of the Georgia Chapter of the American Academy of Pediatrics ((AAP).   Here are some notes, including nutrition committee notes at the bottom of this post. Though not intentional, some important material is likely to have been omitted; in addition, transcription errors are possible as well.

Influenza This Year –Harry Keyserling:

  • 85% of pediatric deaths have occurred in those without influenza vaccine. The vaccine, even when not stopping the influenza (lower efficacy this year), lowers the risk of death.  Probably 50-60% of all Georgia kids are immunized against the flu and  there is a higher rate of immunization (~75%) in younger age (~75%)
  • ‘We are not seeing Tamiflu resistance with this year’s strain’
  • 53 pediatric deaths this year at this point (2/3/18)
  • Children attending public schools have higher rates of vaccination than children attending private schools

Amy Jacobs, Commissioner of Ga Dept of Early Care & Learning (DECAL)

  • decal.ga.gov Website is resource for child care and sponsored meals
  • Georgia Pre-K now in 25th
  • QualityRated.org Useful website for identifying high quality child care
  • ~50,000 children supported with scholarships for childhood care caps.decal.ga.gov 833-442-2277
  • Text “FOODGA” to 877-877 Summer Meal Programs or Call toll free 855-550-7377

Project S.A.V.E.  –Robert Campbell, Richard Lamphier

  • Started in 2004 with the mission of promoting and improving prevention of sudden cardiac arrest (SCA) in children, adolescents and others in Georgia communities..  Website: Project S.A.V.E.
  • Primary prevention: pediatric office, preparticipation physical exams
  • Secondary prevention: after cardiac arrest –emergency action plan
    • Where’s the nearest AED? (Mr. Lamphier’s car).  At our office, GI Care For Kids’ AED –>Formula closet/Stan’s dictation area
    • Is there a plan if an emergency occurs? Name of building, address. Any barriers?
    • Almost always someone is willing to donate AED (~$700) -not a lot of money, this is a process issue much more than a financial one
    • If you wait for an ambulance (~10 minutes) with SCA, you probably won’t need an ambulance –the patient will not survive
  • There are fire drills –last death from fire in Georgia School in 1950s. Schools need emergency action plans in place.  For AEDs to be useful, there is a need for them to be accessible; thus, schools may need to have them in multiple locations.  About 15 pediatric cardiac arrests (data not formally collected) per year in Georgia.

Nutrition Committee Notes:

AAP -Behind the Scenes (Part 2)

Besides the focus on legislation and access to care, the AAP meeting provided an infectious disease update from Dr. Harry Keyserling, membership update by Dr. Roma Klicius, the Pediatric Foundation Report by Dr. Bob Wiskind, an update on oral health care by Dr. Chevron Brooks, a brief update on AAP Friends of Children by Dr. Jay Berkelhammer, and discussion about transitional care.

With regard to the infectious diseases update, Dr. Keyserling noted that despite the flu vaccine’s lower “match” this year and its reduced effectiveness, it is still quite important to receive the flu vaccine.

  • Each year, about 1/3rd ot the population gets the flu.
  • About 1 in 10,000 people die due to the flu.
  • In 2012-13, there were 171 pediatric deaths across the country due to influenza.  90% of these deaths occurred in children who were not immunized; in other words, for a child with the flu, the risk of death is more than 10 times higher in those who do not receive the immunization.

Here are a couple of slides (used with permission) regarding the flu:

Risk of Death from the Flu

Risk of Death from the Flu

Flu Data thru Jan 2015

Flu Data thru Jan 2015

Flu Vaccine Coverage

Flu Vaccine Coverage

Bottomline: The AAP is working on preventing deaths from all vaccine-preventable deaths, including the flu.

Related blog posts:

Since my job at the AAP is to work on nutrition-related issues, I would welcome suggestions for areas of concern.  As there are separate areas devoted to obesity and breastfeeding, my goal is to work on other aspects of nutrition in children.  Some ideas that have come up already include an update on gluten-related disorders and nutritional supplements.  Any other advice?

Upcoming AAP Schedule

Upcoming AAP Schedule

Scarier than Ebola -the Flu

Scarier than Ebola  — From NY Times (an excerpt)

Do me a favor. Turn away from the ceaseless media coverage of Ebola in Texas — the interviews with the Dallas nurse’s neighbors, the hand-wringing over her pooch, the instructions on protective medical gear — and answer this: Have you had your flu shot? Are you planning on one?

During the 2013-2014 flu season, according to the Centers for Disease Control and Prevention, only 46 percent of Americans received vaccinations against influenza, even though it kills about 3,000 people in this country in a good year, nearly 50,000 in a bad one….

On CNN on Monday night, a Dallas pediatrician was asked about what she had advised the families she sees. She said that she urged them to have their children “vaccinated against diseases that we can prevent,” and that she also stressed frequent hand-washing. Ebola or no Ebola, it’s a responsible — and frequently disregarded — way to lessen health risks.

So are these: fewer potato chips. Less sugary soda. Safer sex. Tighter restrictions on firearms. More than 30,000 Americans die from gunshots every year. Anyone looking for an epidemic to freak out about can find one right there.”

“Because It Doesn’t Just Happen to Other People”

While doctors and scientists extol the virtues of vaccination to prevent disease, the emotional arguments regarding vaccines are sometimes lost due to misleading anecdotal stories.  The stories of missed opportunities and suffering due to the lack of vaccination are underreported.

Here’s an excerpt from one that wasn’t:  Link from Eric Benchimol: fw.to/IiBDiOH 

He, our oldest, 5 1/2, who the day before had been jumping merrily on the trampoline at circus school. Monday morning he woke up, out of breath, complaining of a tummy ache…..He came downstairs to watch TV, sank into the sofa, wheezing as if he had just run a marathon…

Everything was not okay. At noon, our big boy was in the pediatric intensive-care unit of the Centre hospitalier de l’Université Laval; he was plugged in everywhere, an oxygen mask covering his whole face, making him look like an astronaut. The respirator was whirring beside him, the oxygen desperately seeking its path, but not finding it…

The doctor said it was time to intubate, “to give him a chance…”

I marvelled at the work of the nurses, the doctors, in a constant death-defying dance. They put in long days and nights, 12 hours at a stretch and more. They obsessed, they never forgot, always determined to make the right decision at the right time.

Thursday morning, they decided to wake up our big boy, to remove the breathing tube, the IVs, trading them for a simple oxygen mask. Friday morning, the mask gave way to two little prongs in his nostrils. His battered lungs still needed some help. But his heart was beating normally again….

Each time I sat down in that blue leather chair, I wondered: “Where did that pneumonia come from? How did he get hit so hard, so fast?”…

The definitive diagnosis came Wednesday night: H1N1.

“Your son wasn’t vaccinated?”

We lowered our heads. Guilty as charged…

So why am I telling you all this? Why would I annoy you with this little story which, after all, happens to countless others every day during flu season?

Because it doesn’t just happen to other people.

Also, a link from the New England Journal of Medicine: nej.md/1hLXqWt 

An excerpt: “Influenza activity has been surging in the United States, and there are reports of critical illness and death in young and middle-aged adults. The predominant virus so far this season is influenza A(H1N1)pdm09, the cause of the 2009 H1N1 pandemic. Despite many challenges, there is much that the public, patients, the public health community, and clinicians can do now to reduce influenza’s impact…”

“Annual influenza vaccination is recommended for everyone 6 months of age or older in the United States..” It is not too late!

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