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This is a page for sharing "what works" as seen in the published literature as well as what is done at sites that care for American Indian/Alaskan Native children. If you have any suggestions, comments or questions please contact Steve Holve, MD, Chief Clinical Consultant in Pediatrics at steve.holve@tchealth.org

March 2012

• Note from the Editor
• Infectious Disease Updates
• Recent Literature on American Indian/Alaska Native Health
• Lucums Tenens and Job Opportunities

Quote of the month

“For there was never yet philosopher that could endure a toothache patiently.”
Shakespeare

Note from the Editor

The 1999 IHS Oral Health Survey showed that 79.7% of children under the age of five years had experienced dental caries. We haven’t had another national survey conducted since then, but everyone in the IHS dental field believes that we haven’t made significant progress with the problem of Early Childhood Caries (ECC). The disparity in the prevalence of this disease in American Indian/Alaska Native (AI/AN) children is staggering—the prevalence of ECC in the general U.S. population in 2004 was 28%, one third the rate in AI/AN children (National Health and Nutrition Examination Survey, 2004).

In July 2009, a select group of dental leaders from across the IHS developed an initiative aimed at preventing ECC. They developed a series of goals which include:

1. Overall Goal: Reduce the prevalence of ECC among 0-5 year old AI/AN children by 25% by FY 2015.

2. Increase dental access for 0-5 year old AI/AN children by 10% in FY 2010 and 50% by FY 2015.

3. Increase the number of children 0-5 years old who received a fluoride varnish treatment by 10% in FY 2010 and 25% by FY 2015.

4. Increase the number of sealants among children 0-5 years old by 10% in FY 2010 and 25% by 2015.

5. Increase the number of Interim Therapeutic Restorations (ITRs)among children 0 -5 years old by 10% in FY 2010 and 25% by 2015.

This dental group also put together a program that includes a packet of information for dental and community partners and two online courses. You can find complete information at the following link: http://www.ihs.gov/doh/documents/ecc/ihsdentalexplorereccinitiative.pdf

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Infectious Disease Updates
Jennifer Cortes, MD, MPH

Prior to the February 2006 ACIP recommendation for routine vaccination of US infants with pentavalent rotavirus vaccine (RV5), rotavirus diarrhea caused an estimated 400,000 outpatient visits, 200,000 emergency department (ED) visits, 55,000 hospitalizations, and 20-60 deaths annually among US children under 5 years of age. RV5 vaccine efficacy (VE) from clinical trial data was 98% for the prevention of severe rotavirus disease and 44% for hospitalization for any diarrhea.1

In a recent observational study using a large claims database, diarrhea-associated healthcare utilization for US children under 5 years of age decreased substantially in each year since vaccine introduction (Figure 1).1 Declines were most notable for hospitalizations but were also present in ED and outpatient settings. The observed reductions exceeded expectations based on RV5 coverage estimations among US children under 5 years of age of only 17% in 2008 and 32% in 2009 (Table 1). This finding suggests indirect benefits of vaccine to unvaccinated children. Observed hospitalization costs were more than $150,000,000 less in 2007-2008 and nearly $120,000,000 less in 2008-2009 than expected costs based on pre-vaccine estimates. Recent surveillance data for 2010 from the National Enteric and Respiratory Surveillance System (NREVSS), demonstrated sustained decline of rotavirus detection for a third post-vaccine season from 2009-2010.3

The aforementioned studies demonstrate impressive declines in rotavirus detection and healthcare utilization for diarrhea disease following RV5 introduction among US children, but the populations studied were not specific to American Indian/Alaska Native children. A recent sub-analysis of American Indian children from RV5 clinical trial data showed that vaccine was 89.5% effective for prevention of G1-G4 rotavirus disease in AI children and similar to the overall study population.2 Although these results are promising, future study will be needed to assess vaccine effectiveness under real working conditions among American Indian/Alaska native children.

1. Vesikari T, et al. N Engl J Med 2006;354:23-33.
2. Cortes JE, et al. N Engl J Med 2011;365:1108-1117.
3. Tate JE, et al. Pediatr Inf Disease J. 2010;30:S30-S34.
4. Grant LR, et al. Pediatr Infect Dis J 2012;31:184-188.

Recent Literature on American Indian/Alaska Native Health
Jeff Powell, MD, MPH

Centers for Disease Control and Prevention. Post neonatal Mortality Among Alaska Native Infants — Alaska, 1989–2009. MMWR 2012;61:[1-5].

This month’s CHN AI/AN pediatric literature review focuses on the important topic of infant mortality in Alaska (specifically post neonatal mortality). The reference report, published in January 2012 by MMWR, describes the difficult challenge of infant mortality in Alaska, and the troubling finding that post neonatal Alaska Native mortality has not declined over the 20 year period, 1989 to 2009.

Multiple efforts have been championed to reduce infant mortality throughout Alaska. This report reflects the great difficulty in impacting improvement with these initiatives. It also highlights the importance of ongoing efforts to find potential underlying causes for the high mortality rates of Alaska Native infants. Perhaps characterizing these causes will lead to targeted screening and intervention that will, in future decades, reduce this important disparity.

The authors reviewed records reflecting 821 infant deaths (ages 28 days to 364 days old) out of more than 222,000 live births to Alaska Residents. The causes of death, and associated maternal factors, were elicited by review of birth and death records, and by State of Alaska Maternal Infant Mortality Review Committee evaluation. All of these data were compiled and analyzed with logistic regression analyses.

Between 1989 and 2009, post neonatal mortality rates in Alaska are highly variable from year to year. Significant disparities were shown between Alaska, and the rest of the United States. This was true both for Non-Native infants (48% higher infant mortality in Alaska), and AI/AN infants (70% higher). Overall, the 20 year period analyzed showed decreased post neonatal infant mortality rates for non-native populations (4.9 per 1000 live births in 1989 compared with 3.9 per 1000 live births in 2009). This reduction was reflected in a single declining slope in incidence after statistical analysis. Sadly, Alaska Native infant mortality did not show a statistically significant decline over the same 20 year period. Rates of Sudden Infant Death Syndrome (SIDS) and Sudden Unexplained Infant Death (SUID) both declined.

Maternal factors associated with post neonatal death were described. Regression models showed that preterm birth, low birth weight, maternal substance/tobacco use, unmarried mother with no father listed on the birth certificate, and low maternal education were all associated with increased risk for sudden death.

The editorial note that follows the report offers additional insights. One important aspect of the effort to characterize and decrease Alaska Native post neonatal mortality is the emerging literature on Carnitine Palmitoyltransferase 1A (CPT1A) Genetic Variant status. CPT1A deficiency is a rare autosomal recessive disorder of fatty acid oxidation that impairs fasting ketogenesis. The genetic variant being examined in Alaska is a partial loss of CPT1A activity, which has unknown implications. In 2010 (Pediatrics, Vol 126 pp 945-951), Gessner et al published preliminary findings of a Newborn Screening analysis for this genetic variant in 616 consecutive AN live births. This effort revealed that 26% of AN newborns have this variant. Further, carriage of the variant allele was found in all cases of infant mortality (and infant death occurred in 5 of the 152 infants homozygous for the allele). All of the cases of infant death were associated with a respiratory infection. While this is a small study that may have limits, it is hoped that this offers an opportunity for further understanding of the historically very high rates of infant mortality in Alaska Native and other circumpolar populations.

Locums Tenens and Job Opportunities

If you have a short or long term opportunity in an IHS, Tribal or Urban facility that you’d like for us to publicize (i.e. AAP Web site or complimentary ad on Ped Jobs, the official AAP on-line job board), please forward the information to indianhealth@aap.org or complete the on-line locum tenens form at http://www.aap.org/nach/locumtenens.htm