Impact of recommendations to suspend the birth dose of hepatitis B virus vaccine.

CONTEXT: In July 1999, due to concerns about thimerosal content, the American Academy of Pediatrics (AAP) and the Public Health Service (PHS) recommended suspending hepatitis B virus (HBV) vaccination at birth except for mothers who had positive or unknown hepatitis B surface antigen (HBsAg) status. In September 1999, the Centers for Disease Control and Prevention recommended that hospitals resume HBV vaccination at birth with a new thimerosal-free vaccine. Whether the 2 changes in recommendations within 3 months led to less-than-optimal compliance in hospital nurseries is unknown. OBJECTIVE: To determine hospital HBV vaccination policy before the recommendation for delay of HBV vaccination and 1 year later. DESIGN, SETTING, AND PARTICIPANTS: Survey of all 46 hospitals with obstetric services and neonatal nurseries in Cook County, Illinois. MAIN OUTCOME MEASURES: Hepatitis B virus immunization practices before July 1999 and in August 2000; hospital factors associated with routine HBV immunization and compliance with AAP and PHS recommendations. RESULTS: Before July 1999, 74% of surveyed hospital nurseries offered HBV vaccine to all neonates; only 39% did so in August 2000. Being located in the Chicago city limits (88% vs 57%; P =.02) and having an academic affiliation (93% vs 66%; P =.05) were positively associated with routine neonatal immunization before July 1999. Both academic affiliation and city location were associated with routine immunization in August 2000 (71% vs 25% [P =.003] and 60% vs 14% [P =.002], respectively) and with compliance with recommendations for suspension (57% vs 25% [P =.03] and 56% vs 10% [P =.001]). CONCLUSIONS: We documented a 35% decrease in hospital nurseries that routinely offered HBV immunization 1 year after the AAP and PHS recommendations were made. Special efforts may be required to make at-birth administration of HBV vaccination universal.

Knowledge of Centers for Disease Control and Prevention guidelines for the use of vancomycin at a large tertiary care children's hospital.

OBJECTIVE: In 1994, the Centers for Disease Control and Prevention (CDC) published guidelines to encourage prudent use of vancomycin. We sought to determine whether physicians could demonstrate knowledge consistent with the guidelines. DESIGN: Survey consisting of 18 clinical vignettes based on the CDC guidelines. PARTICIPANTS: All residents, fellows, and attending physicians involved in pediatric inpatient services. SETTING: Tertiary care children's hospital providing service to an inner-city population and community referral base. MAIN OUTCOME MEASURES: Comparison of survey scores and individual responses among respondents. RESULTS: Survey scores did not vary with level of training or whether the respondent was a pediatrician or non-pediatrician. Average scores of attending physicians, fellows, and residents were 74.1% (SD = 13.1), 77.2% (SD = 11.5), and 73.4% (SD = 10.5), respectively, and did not differ significantly. Questions incorrectly answered by more than 30% of respondents concerned the use of vancomycin as: (1) first-line treatment of Clostridium difficile colitis, (2) a topical solution for wound infection, (3) initial, empiric treatment of patients with fever and neutropenia, (4) peri-operative prophylaxis, (5) a preferred agent over beta-lactam antimicrobial agents. CONCLUSION: Deficits in knowledge regarding appropriate vancomycin use can be localized to certain clinical settings. This observation lends optimism to the notion that targeted educational intervention may improve the appropriate use of vancomycin.

Characterization of an acyclovir-resistant herpes simplex virus type 2 strain isolated from a premature neonate.

Acyclovir resistance is not a recognized problem among neonates with perinatal herpes simplex virus (HSV) infection. A premature newborn with neurocutaneous HSV infection was treated for 21 days with acyclovir. Disseminated disease recurred 8 days later. A recurrent isolate was resistant to acyclovir and lacked thymidine kinase activity on the basis of a frameshift mutation in the thymidine kinase (tk) gene. Compared with the sensitive isolate obtained during primary infection, replication of the resistant isolate was reduced on primary and permanent cells and even further impaired on cells deleted for cellular tk. The resistant isolate lacked virulence in a murine model of genital infection. Acyclovir-resistant HSV-2 mutants can develop rapidly in neonatal infection and cause clinically significant disease, despite decreased replication in vitro and attenuated virulence in an animal model.

Hepatitis B vaccination among children in inner-city public housing, 1991-1997.

CONTEXT: In 1991, the Advisory Committee on Immunization Practices recommended universal vaccination of infants against hepatitis B virus (HBV), with series initiation within days of birth. OBJECTIVE: To determine HBV vaccine coverage in a low-income urban population and to examine whether HBV immunization within the first month of life affects subsequent vaccine receipt. DESIGN: Cohort study based on immunization records collected in the Pediatric Immunization Program. Setting Large public housing development in Chicago, Ill. PARTICIPANTS: All 1143 children who were born between 1991 and 1997 and enrolled between 1993 and mid-1998, with follow-up to age 35 months. MAIN OUTCOME MEASURES: On-time vaccine receipt of HBV vaccine doses, diphtheria-tetanus-pertussis vaccine (DTP) dose 1, and the 4:3:1 series (4 doses of DTP vaccine, 3 doses of poliomyelitis vaccine, and 1 dose of measles-containing vaccine), analyzed by year. RESULTS: On-time HBV vaccination increased quickly following new guidelines and reached a plateau of about 50% coverage for those born in or after 1995. Since 1994, more children (64%) received the first HBV vaccine dose on time than any other vaccine. Children who received a dose of HBV vaccine during their first month of life were more likely to receive the first DTP vaccine dose on time (60.1%) than those who did not get an HBV vaccine dose during the first month (36.4%; chi2 = 53.7; P<.001). Children who received the first HBV vaccine dose during their first month were more likely than those receiving it at age 1 to 2 months to complete 3 HBV doses by 19 months (70.6% vs 51.1%; chi2 = 11.6; P = .001) and to complete the 4:3:1 series by age 19 months (49.8% vs 37.9%; chi2 = 4.0; P = .05). CONCLUSIONS: In this inner-city population, HBV vaccine has been received at rates similar to those of other vaccines within 3 years of issuance of new recommendations. Of note, immunization with HBV vaccine at birth was associated with timely receipt of other vaccines and, therefore, may have the potential to increase vaccination among groups less likely to be up-to-date on early childhood vaccines.