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

Related blog post:

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.

Related blog posts:

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.

Related blog posts:

 

 

 

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: