Annual Meeting, September 14, 2012

NC Pediatric Society Annual Meeting 2012

Day #1

The Battleship North Carolina across the Cape Fear River

Finally, after driving all over the state and as far as Myrtle Beach for these meetings I finally get to welcome my colleagues to beautiful Wilmington, NC! Did I take bribes from local merchants and restauranteurs to direct pediatricians to their establishments? Full disclosure: I tried, but if you're a pediatrician you already know; we're not exactly big spenders.

Dr. Karen Breech, President, NC Pediatric Society

Karen Breach opens her final meeting as out president. Welcomes Dr. Errol Alden, AAP Executive Director. Passing around the microphone, introductions. No karaoke, but maybe next time.

Executive Director Steve Shore, working hard!

Introductions all around

Beth Rowe-West, RN

Vaccine Update

• Deputizing private physicians to give VFC vaccines for underinsured patients if those patients have to drive > 30 minutes to get to a health department. Only about 22 MD’s will be deputized in this way.
• MD’s whose local health departments cannot serve underinsured patients may also qualify for such deputization
• National Immunization Survey: we keep doing worse as a state. We have dropped from 4th nationally to 24th. Part of this fall may be due to missed opportunities to immunize, partly from parents asking to delay and postpone vaccines.
• PCV, Varicella #1, meningococcal, Rotavirus, HPV not currently required, but recommended. Immunization Branch is looking at which of these to require in the future. They are eager to take input from community physicians. Varicella #2 and meningococcus are the most likely to join the required list. She will happily share their data.
• H3N2 influenza vacccine is under development, not yet available.
• Dr. Graham Barden has headed up efforts with the CDC to improve provider compliance with vaccine storage and handling guidelines.
• 60% of NC flu vaccine as already been shipped, the most ever by this time of the year!
• If you have more than one clinical site, you’ll need separate NCIR PIN numbers for each site.
• You must keep a training log for people in your practice who handle and administer vaccines. Online modules are available for this training; there are also live training sessions available throughout the state at various times of year.
• Pertussis is up here by 100%. Sadly, universal Tdap program is ending at the end of this month. Spot coverage may continue in counties with outbreaks.
• Contracts go out Monday (in three days), and this time the CDC has cracked down on contract compliance: no contract, no vaccine!
• NCIR will be interoperable with EMR’s soon, but not in September of this year as their vendor had previously promised. New date to be announced.
• Dave Tayloe mentions the DMA vaccine administration fee ($13.71) has not changed since 1993, despite increased pressure on MD’s to comply with guidelines in vaccine storage and handling. Graham and Christoph are working closely with the CDC to encourage language in their new statement that would urge payers to increase their reimbursement for vaccine administration.
• Dr. John Rusher asks what MD’s can do in terms of advocacy to help the adoption of new vaccine requirements. Beth answers that giving her our input is a great start.

Dr. Alan Stiles, UNC

Dr. Alan Stiles and Dr. Steve Wenger

Child Health Accountable Care Collaborative (CHACC)

• NC is in the bottom quartile for pediatric subspecialists per population of children
• 5% of children consume 53% of Medicaid budget for their care; 30% of adults consume a comparable amount of resources
• This is not an ACO, because that involves shared savings, which are not yet part of the plan but may be in the future.
• Project Director is Steve Wegner, MD of Community Care Of NC. Medical directors include Elizabeth Tilson, MD, David Tayloe, MD, and Alan Stile, MD
• Program directors are Sherri Branski, Rn, MSN, CCM, and Lynn Guerrant, RN, MS
• Care management is already embedded in primary care, but what’s being added is similar management within the children’s hospitals in the state. Care coordinators there will have personal relationships with families of children who have intense medical needs.
• Goals are to improve the health of NC children with complex chronic illnesses through improved value of care.
• Value = Quality of Care divided by Cost of Care. Increasing quality and decreasing cost will both increase value.
• Engage primary care providers and pediatric subspecialists to share responsibility and accountability for pediatric primary, subspecialty, and hospital care.
• Improving communication will be key to this process.
• Jointly develop and utilize evidence-based guidelines of care for pediatric chronic illnesses to help primary care MD’s and specialists co-manage these conditions. Rolling out guidelines for constipation, GERD at this meeting (tomorrow).
• Provide active care management to children under the care of pediatric subspecialists through embedded care managers and patient coordinators at tertiary care hospitals.
• Many of these patients are using their specialists as primary care docs. That care really needs to be provided in the primary care medical home, where it is done better.
• Cost savings should result from reducing re-hospitalizations, improving primary and preventive care for children with chronic illnesses, reducing utilization of emergency services for acute common illnesses, reducing duplication of lab and other studies, reducing pharmacy costs through formularies and evidence-based care.

Dr. Steve Wegner

• While this is not yet an ACO, it would be great for it to become an ACO.
• Success in this project could stave off commercial HMO’s taking over this type of care, preserve our autonomy as providers.
• Project began as a relationship with an IPA in Raleigh, but so far this has just been a referral network. There is potential for that network to become a structure for co-management of patients.
• If a specialist could send care plans to primary care docs and then get those plans back with results, it would enable much better cooperation.
• Currently using data to create a predictive model of where we might be able to improve the current system.
• A “Patient Navigator” could help with socioeconomic problems that impair these patients from getting better care.
• A huge number of re-admissions occur within one month of the first hospitalization. Data identify 2000 patients or so who have at least 3 re-admissions within a one year period, the likeliest initial targets for this program.
• Total NICU graduate readmission costs for the state in Medicaid is over $750 million per year. This does not include the primary NICU admission.
• Patients hospitalized > 1 year with co-morbid physical and psychiatric conditions are another potential target group, accounting for around $15 million

Rob Lamme, Government Relations Consultant (lobbyist)

Tanning Beds And Their Hazards

• Represents the NC Dermatology Association and Community Care of NC
• 2013 promises to see a major legislative debate on the role of private management companies in NC Medicaid. We will need to advocate if we want to preserve CCNC’s nonprofit role in patient management. Now would be a really good time to give to the NC Peds PAC! (must be personal check, not from your corporation)
• If you’d like to talk with your legislator about CCNC’s efforts for patients in your community, contact your CCNC coordinator. Consider inviting legislators to your practice now, while they’re running for office, and let them see what CCNC is doing for you and your patients.
• Your voice really does matter when you talk to your legislators. Go out of your way to take some time and do this. Anticipate helping out with this effort in the next 7-8 months.
• Indoor tanning beds are very dangerous for children, no question in the literature at all. Even ONE use of a tanning bed significantly increases the risk of skin cancer, with the danger increasing with decreasing age.
• Tanning is to your skin what smoking is to your lungs, but the cancer shows up much more quickly.
• NC Dermatology Association, NC Pediatric Society, NC MS, American Cancer Society, NC Child Fatality Task Force, and NC ADvisory Committee On Cancer Control and Prevention all support this legislation.
• Melanoma risk is now 1/74. In 1930 it was 1/1,500
• Ever-use of tanning is associated with a 69% increased risk of early onset basal cell carcinoma.
• 76% of teens live within two miles of a tanning bed!
• Tanning salon = “Cancer shop”
• In NC if you’re over 13 and have a parent’s permission, you can go get skin cancer.
• Most of tanning bed use in minors is at age 16-18 years.
• Vitamin D levels can be maintained with oral supplements, cheap and safe
• Laws in NC restrict children’s access to tobacco, alcohol, driving, pornography, and pseudoephedrine, why not tanning?
• Senate Bill 471, approved by health committee but did not reach Senate floor
• Talk to your legislator, go to Lobby Day at the 2013 legislature
• Engage your medical practice
• Participate in local Cancer Coalition Education And Advocacy

Catherine Goldsmith, MSW

Medicaid Waiver Update for mental health care

• What is a waiver? Permission from CMS to break Medicaid rules
• B-waiver enables networks to include out-of-network providers.
• C-waiver allows use of habilitative and home-based services.
• New waivers will combine both permissions
• Licensed Medical Entity (LME) will have to prove themselves to be effective and efficient in order to stay within the network.
• Department of Medical Assistance (DMA) will monitor waivers, and Centers for Medicaid and Medicare Services (CMS) will monitor the DMA.
• Goal is to improve access for patients, quality of care, and cost-effectiveness of care.
• PIHP = prepaid inpatient hospital plan. That’s the sort of plan that these programs fall under.
• Capitation rates are determined by each area based on patient demographics and needs.
• In fee-for-service model, community support programs tend to mushroom, which does not happen so much in a capitated model.
• Would like to develop more standardized practices across all plans
• LME’s will develop network, decide who is in it, approve services, and pay for services rendered.

Mark O’Donnell, MPH

Role of Evidence Based Practice in Modern Behavioral Health Organizations

NC will have 11 regional Licensed Medical Entity/Managed Care Organizations (LME-MCO’s)

• Because these organizations will be regionally based, they hope to be more responsive to local needs that the prior statewide organization.
• The network of providers will now be closed to only those approved by the local LME-MCO.
• Closed networks have appeared elsewhere to be more focused and stable.
• The LME will handle calls and referrals from patients.
• They will also provide care coordination to make sure patients get to their appointments, have care plans in place
• LME’s will authorize “medically necessary” services
• LME’s will pay the providers, no longer DMA’s job.
• LME’s will educate providers, patients, and the public about how the new system will work.
• LME’s will review providers, deal with appeals and grievances
• Gap analysis: where do savings from effective management of services need to be invested in new services?
• LME’s will collaborate with Community Care Of NC
• The idea is to work in greater partnership with local providers, hope to involve elements of the community not previously involved to get more local input
• MCO’s must hire and enroll psychiatrists, psychologists, licensed mental health ant substance abuse professionals
• Pediatricians are excluded from these regulations by provider type: we can even bill mental health codes for our patients.
• If we have licensed mental health providers in our practices, they will need to apply to the LME-MCO’s to continue to bill.
• Plans that are in trouble will be merged with a more successful LME if they don’t seem to be able to manage services effectively
• Respite, Peer Support Services, and Community Guide are services that may see more spending if the MCO’s are successful in managing their budgets
• Dr. Marston stands to state that their experience with their LME has led about half their providers to drop Medicaid due to excessive paperwork and regulatory burden. Round of applause from many in the room.
• Dr. Lachevitch from Duke University states that many of their psychologists are having a very hard time with the program. Asks how psychologists know when a child can be seen without prior authorization. There are a number of un-managed visits available to each child, but hard to figure out who qualifies and for how many visits. It may take hours just to call someone and get an answer.
• Debbie Ainsworth stands to express that LME may look good on paper due to saving lots of money by not delivering services to patients, wonders where the supervision is coming from. Answer: they will be submitting claims for services to Medicaid, and Medicaid will make sure services appear to be consistent with historical data for the region. There will also be lots of federal oversight. Demands two external reviews and also internal reviews.
• Susan Mims: providers are not getting paid, so they’re no longer taking Medicaid. Answer: there is a complaint line, there is a plan to correct this problem.
• Scott St. Claire: they had a successful co-located mental health provider whom they lost in their office due to the onerous reporting requirements for participating in the LME. Lisa Wainwright is the person at DMA to call with such complaints
• Jane Foy: Piedmont Behavioral Health was the model LME for this program, used to have a great help line for MD’s, which they are now canceling.
• Elizabeth Griffin: she has a high Hispanic population in her county, is there going to be any access for those patients? Answer: we’re looking into it based on Federal requirements.

Dr. Daniel Ostrovsky, DUMC

Dr. Dale Newton, ECU Pediatrics Department Chair

Pediatric Department Chairs

• Welsey Burks, UNC: new for the last nine months. Working on new stategic plans. Hired new MD’s in cardiology, etc. New Med-Peds bioinformatics specialist. Making admissions process easier, welcoming feedback. 29 new residents. Now in second year of primary care track residency program. New RRC requirements take effect next July, will impact clinics, primary care training, specialized training tracks for residents. Med school class is larger, 180. Pediatrics and med-peds are exceptionally popular among UNC medical students who match.
• Ed Spence from Levine Children’s: Dr. Feld is hosting the JCAHO this week, not here. More UNC students will be coming to Charlotte to train, opening up a whole 3rd year MS program there that will run all year. Expanded genetics program, adolescent medicine, pulmonology, hematology, bone marrow transplant, rheumatology, cardiology, pediatric neurosurgery, rehabilitation medicine, developmental-behavioral pediatrics, general pediatrics, hospitalists. Expanded pediatric dialysis unit. New specialty satellite office in South Park neighborhood. Names in six different areas in US News And World Report rankings of best hospitals.
• Dale Newton, ECU: Hospital is now Vident Medical Center, no longer Pitt County Hospital. New has a dedicated pediatric ED! Children’s Hospital construction continues, should be ready to occupy in 10 months. New leadership in almost every pediatric division at ECU. Increased residency program size by 2 per year.
• Daniel Ostrovsky, DUMC: New collaboration with Wake Med, moving a specialty group over to their campus. New GI doc, new neurologist with sleep medicine specialty, new geneticist, new cardiologist. 20 new fellows. New EMR program provides one record per patient throughout the system. Pediatric Academic Society gave Duke Pediatric Teaching Award.
• Wake Forest: Dr. Abramson is preparing for his session

Jane Foy, MD

District IV AAP Report

• Election is underway, closes October 1, please vote!
• Two candidates for Vice Chair, Dr. Stewart, Dr. Gunther
• Two for national nominating committee: Karen Breach (our current president) and Rob Walker from SC.
• New areas of emphasis in AAP Strategic Plan: Early Brain And Childhood Development, emphasizing adverse effects of toxic stress, importance of stimulation and support of young children and their families. Lots of federal advocacy for that issue. Next priority is Epigenetics, heritable changes in gene expression from methylation of genes in response to environmental factors. Toxic stress and chemical exposure are among the causes. Finally Children, Adolescents, and the Media, the newest priority!
• Lots of work going on in federal advocacy, especially in regards to Affordable Care Act, which will increase payments to pediatricians nationwide, making them equal to Medicare!

Errol Alden, MD, Executive Director of the AAP

• AAP Helping Babies Breathe program is now active in 133 countries nationwide, saving newborns’ lives with simple interventions.
• AAP Released 65 policy statements this year, setting standards for pediatric issues both nationally and internationally
• Circumcision statement generated over 8000 emails, many of them critical.

Alice Lenihan, RD, MPH, LDN, Division of Public Health, Nutrition Services Branch

Changes in WIC Program

• Every three years formula contract has to go up for bid by federal law.
• Meade Johnson won for many years
• This year Gerber won the contract
• WIC program is about promoting and supporting breast feeding in NC, but they do provide formula when mothers choose to supplement.
• Over 60% nurse at discharge, but the percentage falls of steadily after those moms go home.
• Gerber Good Start Gentle
• Gerber Good Start Soy
• Gerber Good Start Protect (powder only) has probiotic
• Gerber Good Start Soothe (powder only) has a prebiotic
• Enfamil AR is a standard milk-based formula, not available on WIC under new contract, but available through Medicaid program by Rx
• Nutritionnc.com is the website, with list of exempt formulas through the providers link.
• Thanks to pediatricians for their support of the WIC program.
• Premature formula remains exempt, will remain available through WIC from all manufacturers
• Alimetum and Nutramigen remain exempt and therefore available, as are Neocate and 

Marian Earls, MD, Medical Director, Community Care of North Carolina

CHIPRA

• Child Health Insurance Plan Reauthorization Act
• Provides funding, organization and funding for ongoing activities of Community Care Of North Carolina
• Priorities: EPSDT, Behavioral Health, Oral Health, Medical Home, Asthma, Obesity
• Informatics center can let you look at your own practice’s outcomes and perform quality improvement activities
• New indicator looks at adolescent immunization rates, not just those of two year olds
• Behavioral Health focuses on new ADHD guidelines, identifying adolescent risks and strengths, including depression
• Working on issue of integrated mental health in primary care, where NC has previously been a national model, although new Medicaid waiver process is making that challenging
• Billing codes can track whether we are documenting BMI’s with wellness exams, look for appropriate V codes and make sure your practice’s billing system is capturing those codes.
• Working on making sure kids get timely dental referrals, access to dental care.
• Offering obesity care training for practices around the state.
• Multidisciplinary work group on foster care is at work
• Working on MOC part IV program on postpartum depression screening in primary care
• Surveying adolescents on what they want out of their health care
• NC received funding for three areas in CHIPRA grant: reporting on quality care measures to CMS but also making those measures available to practices via pediatric quality improvement coaches in each network; medical home learning collaborative involving social, emotional, behavioral aspects of care; one of two states to test new pediatric EHR format capable of BP percentiles, prenatal histories, other gaps in EMR’s that handle pediatric data poorly.
• Reinstated pediatric workgroup at CCNC

William “Tex” Parks, North Carolina State Laboratory of Public Health

Lead Testing Guidelines

• New action thresholds for lead testing, now 5 mcg/dl instead of 10 mcg/dl
• Lead level 5-9, notification, nutritional assessment, environmental history, follow-up testing q 3 months until two results are <5
• 10-19 all of the above, plus WIC referral, health department environmental investigation, re-test q 1-3 months, test other kids in the home
• 20-69 required environmental investigation, referral to CDSA or Child Service Coordination Program, Social Services referral. Testing q month
• >70 Hospitalize for medical treatment.
• We will be seeing four times as many lead tests as we used to, but could be as high as tenfold increase!
• Make sure patient Medicaid and social security numbers are used, accurate
• In-house testing units often don’t detect lead levels under 3.5
• Chemical terrorism and threat unit will be absorbing the lead testing unit at the state level. They get to use better equipment for blood testing (ICP/MS instead of graphite furnace AA for those who care). The ICP unit is more sensitive, more specific than the old graphite furnace
• New equipment reports levels out to the hundredths level, give faster results
• Can call William “Tex” Parks at 919-807-8771 or cell 919-602-2481. He is the chemical/terrorism coordinator, so don’t be surprised if that’s how he answers the phone. Also Kate Mason is available.
• Lead test results are not yet on the Newborn Screening website, but the plan is to get them there as soon as possible.

Lunch!

President-Elect John Rusher opens the business meeting

Business Meeting

Jennifer Talbot, Prevent Blindness NC

• Moment of silence for passed members
• Recognition of Executive Committee members
• Good For Kids Award: Prevent Blindness NC, Jennifer Talbot
• Treasurer’s Report, Scott St. Clair. Basically on track to meet our budget for this year.
• Membership report, approval of new members. We have 188 new members since last year! So approved.
• Leadership Development, Dr. Marian Earls: Scott St. Clair, Secretary; Kenya McNeil-Trice, Treasurer; Debbie Ainsworth, Vice President, new at-large member, Kathleen Clarke-Pearson.
• Peter Morris and John Rusher discuss proposed merger of the NC Pediatric Society and the NC Pediatric Society Foundation. Consulting firm is helping with the logistical aspects of this effort.
• Kenya McNeil-Trice on educational program. Excited about Dr. Klass’s plenary speech. Largest number of resident programs ever this year! 

Dr. Perri Klass

Dr. Perri Klass, National Medical Director, Reach Out And Read

• ReachOut and Read is a school readiness program. Involves pediatric primary care providers giving books to children from ages 6 months to five years along with literacy advice to their parents at wellness exams.
• We reach most parents and children, have repeated contact with families, provide trusted guidance, may serve ast the only source of formalized suport for poor families.
• We think about kids in poverty, but these ideas matter for children from all socioeconomic strata
• Families look not only to the providers, but to everyone in our office for information on what they need for their children.
• Doing the things we already do, but around the book, can be even more effective
• Three componsnets: The first is in the waiting room with information, displays, gently-used books, volunteer readers. At Bellevue they use mats on the floor for reading. 
• Exam room component: anticipatory guidance. This is all advice we’re already giving. Promotes reading and talking to babies, children. Reinforces sleep habits, for example. Involves routines, setting limits, touch, turning off the TV, having a realistic expectation of a child of a given age.
• For example, 6 month olds eat books. 12 month olds point with one finger. 18 month olds turn board book pages. 2 year olds may not sit still and listen. 3 year olds can re-tell familiar stories.
• By kindergarten a child will have received 10 books, each developmentally appropriate for the age at the time of the visit.
• Books are introduced early in the visit and integrated into the examination within the context of other anticipatory guidance.
• The book can serve as a developmental indicator for the child and also give a lot of clues about how the parent relates to the child.
• Reach out and read is in nearly 5,000 locations in all 50 states, DC, Puerto Rico, and the US Virgin Islands. 80% of the children reached are below 200% of the official poverty level.
• North Carolina has added 50 programs in 20 months and has 50-75 on the waiting list to start, in part due to a strong relationship with the North Carolina Partnership For Children/Smart Start.
• After 22 years and 45 million books, what are lessons learned?
• Problem: well-recognized, children growing up in language-poor and print-poor environments see poor vocabulary development. The divergence widens every year. This puts kids at risk for school failure. Around 1/3 of American kids start school without the basic language skills needed to learn to read, and that number has been stable for decades.
• About 1/3 of fourth graders do not read at grade level, which is critical, because this is that age at which the rest of learning becomes reading-dependent.
• Kids who are struggling in first grade do not tend to catch up later on, but they continue to struggle throughout their school careers.
• These are kids who will spend 7 hours a day in a place that does not make them feel very good, because they don’t do well there.
• Juvenile offenders are often kids who don’t read very well.
• Can books be used to fulfill the Bright Futures Guidelines in the exam room, therefore making the office visit efficient?
• At six months visit the book can be used to see if a baby looks at faces, sits up stably, interacts with mom, uses an age-appropriate grasp, brings the book to his mouth. Similar milestone evaluation can be done at 9 months, 12-15 months, etc.
• 12 month old will follow parent around, poke parent with the book, seek the type of physical and auditory contact he wants. Can frame this as being a tribute to the parent.
• Book selection: know your population. What is the literacy level of the parent? Can talk about looking at the book or naming pictures. Do they have that book at school? They’ll want that one!
• Board books are good for 6 months and 12-24 month olds, although the older kid books are more geared toward ideas, rhymes. Two-year-olds can handle paper pages. More rhyming, numbers, humor at those ages.
• Books can be mirrors, or windows to new and different worlds.
• What is the evidence behind this intervention? Does it work?
• ROR parents were four times more likely than others to mention reading to their child in the last 24 hours
• Receptive and expressive vocabulary scores increase in toddlers around 17 months of age when books are given compared to when they are not
• Many more parents read to their kids in the intervention group
• Mendelsohn, et al 2001 found dramatic improvements in receptive and expressive language in intervention kids compared to kids not given books.
• There are resources for providers to initiate the program in Spanish.
• For this to work, parents have to have reading skills, must understand the importance of reading, and children have to have developmental and behavioral skills to participate.
• Home needs to be stable, have schedules, rituals. So the book can open up discussions about all these subjects
• North Carolina serves as a model for this program due to its strong organizational pediatric strength, dedicated pediatricians with strong community roots.
• www.reachoutandread.org
• www.rorcarolinas.org
• www.myROR.org (requires site ID and password)
• What do you say to a parent who is more proud of the iPad or DVD the kid uses? Answer: parent is special; only you can give your child this type of attention and teaching.
• In response to a question from Paul Trani: “Language confusion” in bilingual families is largely nonexistent, should not be used as an excuse for poor school performance in kids from bilingual families.
• Bilingual books are especially useful in immigrant families.
• Giving the child a book demonstrates your belief in the child’s ability to use it
• You may want to ask a lot of parents if they are interested in improving their reading skills, which of course would require a relationship with an adult literacy program to send them to.

Jon S. Abramson, MD

Chair Of Pediatrics, Wake Forest University Medical School

Global Health: Is Good Ever Good Enough?

• Since 1970 there has been at least one new emerging infection per year.
• Improving public health demands improving poverty.
• Most of the world’s population lives in areas categorized as “lower middle income”
• Birth rates fall with increased wealth, independent of all other factors
• Global burden of child deaths is mostly due to infectious disease in developing countries
• Millennium Development Goals (MDG) adopted by >190 countries in 2000, with goals to be achieved by 2015, provide an international framework for public health
• If achieved, world poverty would be cut by half, and tens of millions of lives would be saved.
• MDG included 21 identifiable targets
• Tools that can enable the vision include enhanced public health and education infrastructure, immunizations, technology such as mobile phones and internet access
• Goal 1: Poverty target, already achieved, cut by half! Hunger target, not.
• Goal 3: promote gender equality and empower women. Gender equity achieved for primary but not secondary education
• Goal 4: reduce child mortality by 1/3. Done, 37%.
• Goal 5: reduce maternal mortality by 75%. Not on target. The US is the only developed country with numbers comparable to developing nations.
• Goal 6: combat HIV/AID, malaria, and other diseases. Still working on that one.
• Goal 7: ensure environmental sustainability. halve the proportion of people without access to safe drinking water and basic sanitation. There, but not for sustainable development.
• Goal 8: develop a global partnership for development. Delayed by global recession.
• Regarding goal #4, deaths of children in developing countries have fallen dramatically, largely due to immunization efforts, 288 million more children immunized in developing countries. Prevented >5,000,000 deaths.
• Better vaccine coverage could avert an additional 2,000,000 deaths a year.
• GAVI’s (Global Alliance For Vaccines And Immunization) enormous worldwide orders for vaccine have driven down prices for many vaccines
• Chinese and Indian vaccine companies are starting to enter the market with large volume capabilities.
• In 2010 the US announced a new Global Health Initiative, investing $63 billion in improving women’s and children’s health worldwide, which reduces disease here in the US
• Gates Foundation has declared the Decade Of Vaccines, working on malaria, TB, others
• The Meningitis Belt of sub-saharan Africa has dramatically increased cases of meningococcal disease compared with other regions. Epidemics due to serotype A, occurs every 7-12 years.
• Gates Foundation is vaccinating everyone in the region aged 1-29, deaths cut from 88,000 to 5.
• Influenza: pregnant women have a 4-10x risk of severe infection compared to non-pregnant women, worse during the 2nd and 3rd trimesters. Death rate for hospitalized women = 11%!
• Immunizing pregnant moms decreases incidence of flu in infants up to age 6 months
• In pregnant women with severe flu a very high percentage of neonates are admitted to the NICU or died.
• Pregnant women are now the #1 priority for flu vaccine in all countries
• Three test questions of whether good is good enough:
• Should the age restrictions for rotavirus vaccine be discontinued? Rotavirus kills 453,000 children a year, with 82% of these deaths in 20 countries in the developing world.
• Rotavirus vaccine probably causes about 4/100,000 cases of intussusception
• Without age restriction we would see around 42,000 fewer worldwide deaths from rotavirus, about 317 additional deaths from intussusception. Because US death rate is so much lower this is probably not a great policy for the US.
• Should the global polio eradication effort be continued?
• Polio has been eradicated in India, which used to be the worst country. Now Pakistan and Afghanistan are hot spots, along with Nigeria and Chad, Congo and Angola.
• Polio eradication costs around $2 billion per year. We have already missed two deadlines, and donors are fatiguing of the effort. Plan is for one more intense global effort, using GPS to make sure the vaccination personnel are actually going to people’s houses. Bivalent oral vaccine is more effective.
• Should we declare a deadline for global measles eradication?
• Endemic measles has been eliminated from North America and South America. But Europe remains a hot spot, and travelers continue to bring it here.
• As recently as 1980, measles caused 2.6 million deaths a year. In 2010 it was 140,000.
• US cases quadrupled in 2011. Vaccine hesitancy is the whole problem in France, leading to over 40,000 cases last year. WHO has formed a vaccine hesitancy working group to address this problem.
• We cannot eradicate measles without first overcoming vaccine hesitancy.