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PRIORITY PRESS - McGill Faculty of Medicine 62nd Annual Refresher Course for Family Physicians

Montréal, Quebec / December 5-7, 2011

Montréal - During this year’s widely attended McGill Refresher Course, delegates learned of recent National Advisory Committee on Immunization (NACI) updates for immunization against 3 paediatric diseases. NACI recommends that the pneumococcal 13-valent conjugate vaccine (PCV13) should be used for primary infant immunization against pneumococcal disease, and toddlers in daycare should receive a PCV13 booster shot. NACI advises that children should now receive 2 doses of varicella vaccine and also recommends that all healthy infants should be vaccinated with a rotavirus vaccine. For invasive meningcoccal disease, a very severe and overwhelming infection, the 4CMenB vaccine is expected to be implemented into clinical practice in the next year. In another plenary session, the “top 5” paediatric articles of 2011 were summarized and in a workshop devoted to paediatrics, participants discussed typical cases in practice.

Chief Medical Editor: Dr. Léna Coïc, Montréal, Quebec

“A universal immunization program is key for protecting our children,” Dr. John Yaremko, Assistant Professor of Paediatrics, McGill University, Montréal, Quebec, told delegates during a plenary session entitled “Vaccinations: Latest Developments.”
“By the time they are 2 years old, 80% of kids in Quebec and about 72% of kids in Canada have had all their vaccines,” he noted.
Dr. Yaremko suggested these low numbers were probably due to cost rather than parents not wanting their children to be vaccinated.

Vaccine Update

The National Advisory Committee on Immunization (NACI) recommends that the pneumococcal 13-valent conjugate vaccine (PCV13) be used for routine infant immunization against pneumococcal disease and, importantly, that healthy 3- to 5-year-olds who are aboriginal or in daycare need a PCV13 booster shot, Dr. Yaremko informed delegates. “We started with the 7-serotype vaccine, followed by the 10-serotype vaccine, and last year the 13-serotype vaccine, PCV13, was authorized,” he explained. Although protection has risen to over 70%, pneumococcal disease caused by non-vaccine serotypes has steadily increased. In North America, the “main culprit,” serotype 19A (often a multidrug resistant form), accounted for almost 50% of cases in 2009, while serotype 3 accounts for 7% of cases. These shortfalls are addressed in PCV13, which includes both serotypes. Quebec, Ontario, Alberta and British Columbia have already implemented a 3-dose vaccination series with PCV13, with 4 doses recommended for premature infants or other high-risk children. NACI also recommends 2 PCV13 doses for infants aged 12 to 23 months who have not received a conjugate pneumococcal vaccine.

Last September, NACI recommended giving 2 doses of varicella vaccine instead of 1 dose. Despite the success of a publically funded varicella immunization program in Canada, “about 5% of kids who get varicella have a significant varicella and are at risk for complications requiring hospitalization,” Dr. Yaremko reported. Evidence also suggests that immunity may wane with time and the disease may be shifting to an older population with greater risk of complications. NACI recommends a second varicella vaccine dose for children who have already been vaccinated but have had no breakthrough infection. Children between 12 months and 2 years should receive primary immunization with 2 doses given at 12 to 15 months and 18 months or 4 to 6 years. Susceptible adolescents and adults as well as children with certain immunodeficiency diseases should still receive 2 doses.

The Canadian Paediatric Society echoes these recommendations. “In some classrooms, as many as 40% of vaccinated children developed varicella,” Dr. Yaremko reported. The median age of disease onset crept from 5 years to 8 years among vaccinated children and 13 years among non-vaccinated children. However, vaccine efficacy was 98.6% in children who had received 2 vaccine doses. The experience in the US has been similar. In June 2006, the US Advisory Committee on Immunization Practices (ACIP) recommended routine immunization with 2 doses of varicella vaccine for children younger than 13.

In July 2010, NACI recommended that all healthy infants should be vaccinated with the pentavalent rotavirus vaccine or the newer monovalent rotavirus vaccine at age 6 weeks to 15 weeks, because rotavirus gastroenteritis is so common among young children. “It accounts for 40,000 doctor visits, 17,000 emergency room visits and more than 5000 hospitalizations each year in Canada and is definitely the most common cause of gastroenteritis and dehydration in kids under 5,” confirmed Dr. Yaremko. Second or third children in a family, children in daycare and premature infants are at highest risk. The monovalent rotavirus vaccine which is part of the universal immunization program in Quebec and Ontario, is given in 2 doses and the pentavalent rotavirus vaccine is given in 3 doses. NACI strongly recommends giving the first dose between 6 and 15 weeks because children who had intussusception following vaccination with an early quadrivalent rotavirus vaccine in the late 1990s had been vaccinated later. The second dose should be given before 8 months. Preterm infants can receive the rotavirus vaccine but it is contraindicated in immunocompromised children.

Commenting on the meningococcal serogroup B (4CMenB) vaccine against invasive meningococcal disease, Dr. Yaremko reported: “There’s no question that there is a need for this vaccine.” Now, over 97% of invasive meningococcal disease in teens and children in Quebec is caused by serotype B, which is not targeted by vaccines currently in use. About 60% of children who acquire this disease end up in the intensive care unit (ICU) within 24 hours. “Kids will see their doctor and the doctor will send them home with a diagnosis of a viral, flu-like illness; then, 12 hours later, the kids deteriorate drastically and end up in the hospital ICU, and 10 to 15% of them will die,” Dr. Yaremko added. Treatment success has not improved much over the past 40 years, despite increased awareness of the disease, improved antibiotics and better-equipped ICUs. According to Dr. Yaremko, “This new vaccine which hopefully will be available by the summer is the answer, in terms of protecting a lot of children against this terrible disease.”

The “Top 5” of 2011

Dr. David McGillivray, Division of Emergency Medicine, Department of Paediatrics, McGill University, presented 5 potentially practice-altering articles.

Article 1: Chest X-rays and pneumonia (Neuman et al. Pediatrics 2011;128:246-53). In a cohort of more than 2500 children who presented to an emergency department and had a chest X-ray for suspected pneumonia, an oxygen saturation < 92% was linked with a 3.6-times increased risk of having pneumonia. Among patients with oxygen saturation >92% and no history of fever, focal decreased breath sounds and or focal râles, only 7.6% had radiological pneumonia. “You have to be careful who you do X-rays on; if the patient has no clinical signs of pneumonia, it isn’t likely to be bacterial pneumonia,” Dr. McGillivray cautioned.

Article 2. Cephalexin vs. clindamycin for skin infections (Chen et al.
Pediatrics 2011;127:e573-80). In this American study, 69% of 200 paediatric study patients had methicillin-resistant Staphylococcus aureus (MRSA). Complete resolution at 7 days was similar with cephalexin (97%) and clindamycin (94%). “Close follow-up and fastidious wound care of appropriately drained, uncomplicated skin and soft tissue infections are likely more important than initial antibiotic choice,” the authors concluded.

Article 3. Vulvovaginitis. (Curran et al. Pediatrics 2011;127:e1081-5). Four adolescent girls in Manitoba who sought treatment for vulvovaginitis were subsequently found to have type 2 diabetes.

Article 4. Seizure recurrence (Martin et al. Pediatrics 2010;126:e1477-84). In a longitudinal study of 117 children with first-time seizure, co-existing fever did not predict seizure recurrence, but co-existing acute gastroenteritis did predict a low rate of seizure recurrence.

Article 5. Blood cultures and pneumonia (Shah et al. Pediatr Infect Dis J 2011;30:475-9). Among over 9000 children who were evaluated in the emergency room for community-acquired pneumonia, 291 children had blood cultures and 6 patients were found to have bacteremia (Streptococcus pneumoniae in 4 cases). Following the blood culture results, antibiotic coverage was broadened in 4 cases and narrowed in 1 case. Dr. McGillivray cited a noteworthy Practice Point by Le Saux et al. on the management of paediatric pneumonia (Paediatr Child Health 2011;16:417-24). “What is new is that for previously healthy children 3 months to 17 years with community-acquired radiologically proven pneumonia, the authors recommend amoxicillin as first-line therapy over cephalosporins and macrolides.”

Noteworthy Cases

In a workshop entitled “Common Problems in Pediatrics,” Dr. Yaremko presented 3 often-seen cases.

Case1: A 1-month-old infant seen for “noisy breathing” had intermittent, persistent stridor with no associated skin disorders and was diagnosed with laryngotracheomalacia. This presents between 2 and 4 weeks and tends to resolve between 12 and
24 months.

Case 2: A 10-month-old child with a sacral dimple. “It is important to check the spine for a second dimple,” Dr. Yaremko noted. He advised, “If the patient also has cutaneous findings, do an MRI. If there are multiple dimples with a diameter greater than 5 mm, located more than 2.5 cm above the anal verge, do an ultrasound. If there is a solitary sacral dimple, do routine care. ”

Case 3. Pharyngitis. The key messages are that children under 5 years old or those with viral symptoms (runny nose, hoarseness) do not have strep; a quick strep test is very reliable but has a high false-negative rate, so if the test is negative, consider doing a culture.

Summary

The highly interactive meeting offered 28 plenary sessions and 80 workshops covering a wide range of topics and attracted family physicians from across Canada and internationally. “Carefully chosen speakers presented the latest information that can change and improve clinical practice,” stated the meeting’s Course Director, Dr. Ivan Rohan, Interim Associate Dean of Continuing Health Professional Education and Assistant Professor, Department of Family Medicine, McGill University. 

Note: Session presentations are available online at www.course-mcgill.ca

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