Fall 2016 Issue

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Messsge from the EditorEditor's Corner

Fatal Abusive Head Trauma in Children

By Robert G. Locke, DO, MPH, FACOP


Robert G. Locke, DO, MPH, FACOP
Robert G. Locke, DO, MPH, FACOP

Abusive head trauma is the cause of death in one third of child abuse fatalities. Fortunately, fewer children are dying from abuse inflicted head injuries such as violent shaking or blunt trauma. For the decade between 1999-2009, there was no meaningful decrease. Since 2009, there has been a 51% decrease. There is growing evidence that preventative strategies modifying parents and other caregiver behaviors are behind this recent change. In addition to individual-based strategies, community-level strategies such as economic stability, family integrity and family-friendly work policies, such as paid parental leave, hold additive beneficial potential. The 13% average annual decline from 2009 after a decade of no progress is laudable, but more can be done.

Figure 1The CDC has free technical support packages for communities and can be found HERE.

The CDC also has good web-based parent-oriented resources within their “Essentials for Parenting Toddlers and Preschoolers” help section and can be found HERE.

Other sections focus on communication skills, constructively establishing household structure and rules, as well as methods to optimize “time out” and use of “consequences”.

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Editor's Corner

FluMist (non-injectable live attenuated influenza vaccine):
High Quality Science and Don’t Bet Against Its Future

By Robert G. Locke, DO, MPH, FACOP

Time Line:
2007: NEJM Publication:  55% greater efficacy with FluMist compared to injectable vaccine in children.
2013: CDC recommended FluMist as one option for children greater than two years of age.
2014: CDC preferential recommendation for FluMist to injectable vaccine in two-eight year olds.
2016: CDC’s Advisory Committee for Immunization Practices (ACIP) reversal to recommended avoidance of FluMist and preferential for injectable vaccine.

What changed? Did the CDC originally make a mistake? Or was this good translational science and good public health policy all working together to tackle a complex moving target?

flumistFirst of all, the CDC’s Advisory Committee for Immunization Practices (ACIP), is doing its job well. ACOP’s Stan Grogg, DO, FACOP, is a member of ACIP’s evaluation committee. ACIP meets three times a year to critically evaluate vaccine efficacy and make recommendations. Thus, when the evidence changes, ACIP is able to make timely recommendations.

In this case, what changed was the efficacy of the FluMist to the current influenza virus. In the 2015-2016 FluMist was <5% effective against flu strains in children two-seventeen years of age compared to the injectable efficacy in the 60% range. (AstraZeneca disputes the CDC data and claims that the efficacy rate is significantly higher. FluMist remains an approved and available vaccine.)

Although the exact reasons are still being elucidated, the reasons for the changed efficacy provide valuable insights into understanding the challenges of vaccine medicine.

One major potential reason for the decreased efficacy is the change in influenza strain. When FluMist was originally evaluated, different H3N2 versions of the virus were the dominant strains. FluMist also has poor efficacy against the H1N1 strains that are now dominant. H1N1 is dominant now, but may not dominate in the future.

Another potential reason for the decreased efficacy is through the mechanism of action. From a parent/child perspective, the FluMist was preferred since it avoided a shot and was potentially more effective than the injected inactivated vaccine. The nasal administration to the mucosal surface induced local immunity, reduces viral shedding and less contagious. However, repeated yearly administration using this local nasal immune response may be counterproductive. A theoretical concern is that there may be enough antibodies created from previous same strain nasal attenuated influenza exposure to interfere with the individual’s immune response, blunting the ability to amount an effective response when exposed to the actual virus. In addition, there is some concern that changing from a trivalent to quadrivalent vaccine caused cross inhibition with diminished host response to the other components.

The potential of nasally administered live attenuated influenza vaccine still has a promising future, especially if the lessons learned from FluMist’s diminutive response over time are incorporated into future strategies. Battling a multidimensional dynamic disease process requires creative strategies, real-time monitoring and constant adjustments. These have been successfully displayed in the ongoing and yet uncompleted story of nasal administration of live attenuated viral vaccines.

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ACOP Pediatric Track at OMED 2016


ACOP Pediatric Track
at OMED 2016

September 16-19, 2016
Anaheim Convention Center
Anaheim, California