Incidence of herpes zoster among varicella-vaccinated children, by number of vaccine doses and simultaneous administration of measles, mumps, and rubella vaccine.

INTRODUCTION: Children may receive measles-mumps-rubella (MMR) and varicella (VAR) vaccines separately or as measles-mumps-rubella-varicella (MMRV). We examined whether pediatric herpes zoster (HZ) incidence varied by pattern of varicella vaccine administration. METHODS: In six integrated health systems, we examined HZ incidence among children turning 12 months old during 2003-2008. All received varicella and MMR vaccines on recommended schedules. Cases were identified through 2014 using ICD-9 codes. Incidence was examined by number of varicella vaccine doses and same-day MMR. RESULTS: Among 199,797 children, overall HZ incidence was 18.6/100,000 person-years in the first-dose MMR + VAR group, 17.9/100,000 person-years in the MMRV group, and 7.5/100,000 person-years in the VAR-alone group. HZ incidence was lower following the second dose than before the second dose in all first-dose groups. CONCLUSIONS: HZ incidence was not meaningfully different between the MMRV and MMR + VAR first-dose groups. Overall and within first-dose groups, HZ incidence was lower among children receiving two varicella vaccine doses.

Incidence of Herpes Zoster Among Children: 2003-2014.

BACKGROUND AND OBJECTIVES: After the 1996 introduction of routine varicella vaccination in the United States, most studies evaluating pediatric herpes zoster (HZ) incidence reported lower incidence over time, with varying degrees of decline. Using the combined databases of 6 integrated health care organizations, we examined HZ incidence in children over a 12-year period in the varicella vaccine era. METHODS: This study included children aged 0 through 17 years from 2003 through 2014. Using electronic medical records, we identified HZ cases through International Classification of Diseases, Ninth Revision diagnosis code 053. We calculated HZ incidence rates per 100 000 person years of health plan membership for all children and among children who were vaccinated versus unvaccinated. We calculated rates for the 12-year period and examined temporal trends. Among children who were vaccinated, we compared HZ rates by month and year of age at vaccination. RESULTS: The study included 6 372 067 children with ≥1 month of health plan membership. For the 12-year period, the crude HZ incidence rate for all subjects was 74 per 100 000 person years, and the rate among children who were vaccinated was 38 per 100 000 person years, which was 78% lower than that among children who were unvaccinated (170 per 100 000 person years; P < .0001). Overall HZ incidence declined by 72% (P < .0001) from 2003 through 2014. Annual rates in children who were vaccinated were consistently lower than in children who were unvaccinated. CONCLUSIONS: With this population-based study, we confirm the decline in pediatric HZ incidence and the significantly lower incidence among children who are vaccinated, reinforcing the benefit of routine varicella vaccination to prevent pediatric HZ.

Poststreptococcal Reactive Arthritis: Diagnostic Challenges.

Poststreptococcal reactive arthritis (PSRA) is associated with prior group A ß-hemolytic streptococcal infection and has a reported annual incidence of 1 to 2 cases per 100,000 persons, approximately twice that of acute rheumatic fever (ARF) in the US. Children who present with reactive arthritis are not uncommon in a busy general pediatric practice in the US, whereas children who present with ARF are very rare. Distinguishing PSRA from ARF can be challenging because the symptoms and signs are similar, but the diseases differ in long-term therapy, follow-up evaluation, and prognosis. We review the diagnostic criteria for PSRA, the pertinent features of the 2015 ARF diagnostic guideline from the American Heart Association, and the major characteristics that differentiate PSRA from ARF.

Family Characteristics Associated with Likelihood of Varicella Vaccination.

CONTEXT: The introduction of the varicella vaccine as a routine pediatric immunization in the US, in 1995, provided an opportunity to assess factors associated with uptake of new vaccines in the member population of the Kaiser Permanente Northwest (KPNW) Health Plan. OBJECTIVE: Identify factors associated with varicella vaccination in the KPNW population in the first five years after varicella vaccine was introduced. DESIGN: A retrospective cohort of children under age 13 years between June 1995 and December 1999, without a history of varicella disease was identified using KPNW automated data. Membership records were linked to vaccine databases. Cox regression was used to estimate likelihood of varicella vaccination during the study period in relation to age, sex, primary clinician's specialty, and Medicaid eligibility. For a subset whose parents answered a behavioral health survey, additional demographic and behavioral characteristics were evaluated. MAIN OUTCOME MEASURE: Varicella vaccination. RESULTS: We identified 88,646 children under age 13 years without a history of varicella; 22% were vaccinated during the study period. Varicella vaccination was more likely among children who were born after 1995, were not Medicaid recipients, or had pediatricians as primary clinicians. In the survey-linked cohort, positively associated family characteristics included smaller family size; higher socioeconomic status; and parents who were older, were college graduates, reported excellent health, and received influenza vaccination. CONCLUSION: Understanding predictors of early varicella vaccine-era vaccine acceptance may help in planning for introduction of new vaccines to routine schedules.

Positive Predictive Value of ICD-9 Code for Herpes Zoster Among Children During the Varicella Vaccine Era.

We examined the positive predictive value of the herpes zoster ICD-9 diagnosis code 053 in the Kaiser Permanente Northwest integrated health plan. Among children 0-17 years old, the positive predictive value was 87.1% (95% confidence interval: 84.2-89.6) and 96.8% (95% confidence interval: 95.0-98.1) during the years 1997-2002 and 2005-2009, respectively, using chart review of the medical record as the diagnostic standard.

A Ten-Year Case-Control Study of Passive Smoke Exposure as a Risk Factor for Pertussis in Children.

The authors conducted a matched case-control study of laboratory-confirmed pertussis cases, occurring from 1/1/1996 to 12/31/2005, in children up to 12 years of age who were members of a large managed care organization. Sixty-five laboratoryconfirmed cases of pertussis were identified. Using multivariable conditional logistic regression analysis, the authors did not detect a statistically significant association between pertussis and household passive exposure to cigarette smoking.

Passive cigarette smoke exposure and other risk factors for invasive pneumococcal disease in children: a case-control study.

OBJECTIVE: To investigate whether passive cigarette smoke exposure increases the risk of invasive pneumococcal disease in children. METHODS: In a population-based case-control study, 171 children aged 0 to 12 years with culture-confirmed invasive pneumococcal disease during the years 1994 to 2004 were identified. Two controls were matched to each case on age and patterns of Health Plan membership. We reviewed medical records of subjects and family members for information on household cigarette smoke exposure within 2 years of the diagnosis of invasive pneumococcal disease. We collected information on sex, race, pneumococcal vaccination, selected medical conditions, and medications in the 3 months before the diagnosis. RESULTS: Similar proportions of cases (25%) and controls (30%) had definite or probable passive smoke exposure (odds ratio [OR] = 0.76, 95% confidence interval [CI] = 0.47-1.2). Cases of invasive pneumococcal disease were more likely to be nonwhite than controls (OR = 4.4, 95% CI = 2.3-8.2). Elevated risk of invasive pneumococcal disease was found in subjects with recent pulmonary diagnoses (OR = 2.2, 95% CI = 1.2-4.0) and recent antibiotic use (OR = 1.6, 95% CI = 1.1-2.3). CONCLUSIONS: Passive cigarette smoke exposure was not associated with invasive pneumococcal disease in this pediatric population. Invasive pneumococcal disease was associated with recent pulmonary diagnoses and recent antibiotic use.

Incidence and clinical characteristics of herpes zoster among children in the varicella vaccine era, 2005-2009.

BACKGROUND: Vaccine-strain herpes zoster (HZ) can occur after varicella vaccination. This study determined the number and proportion of HZ cases caused by vaccine-strain varicella zoster virus (VZV), assessed the positive predictive value of provider diagnosis of HZ, and computed HZ incidence rates in vaccinated and unvaccinated children. METHODS: We used electronic medical records to identify all office visits with an HZ diagnosis for children aged <18 years in a managed care plan. Providers collected skin specimens and completed a questionnaire. Specimens were tested by polymerase chain reaction to identify wild-type or vaccine-strain VZV. RESULTS: From May 2005 to September 2009, we enrolled 322 subjects. VZV was detected in 82% of specimens (84% wild-type, 15% vaccine-strain, 1% possible vaccine-wild-type recombinant). Among the 118 vaccinated subjects, VZV was detected in 70% (52% wild-type). The positive predictive value for provider diagnosis of "definite HZ" was 93% for unvaccinated and 79% for vaccinated children. The incidence of laboratory-confirmed HZ was 48 per 100,000 person-years in vaccinated children (both wild-type and vaccine-strain) and 230 per 100,000 person-years in unvaccinated children (wild-type only). CONCLUSIONS: HZ incidence in vaccinated children was 79% lower than in unvaccinated children. Among vaccinated children, half of HZ cases were due to wild-type VZV.

Laboratory characteristics of suspected herpes zoster in vaccinated children.

Varicella vaccination of children has decreased varicella disease incidence, but introduced the occurrence of herpes zoster (HZ) from vaccine-type virus. We identified 14 vaccinated children with suspected HZ and confirmed varicella virus by polymerase chain reaction in 6 cases. Two cases were due to vaccine-type virus. Serum varicella IgM and IgG were not useful for diagnosis of HZ among vaccinated children.

Global neurologic deficits with baylisascaris encephalitis in a previously healthy teenager.

We present a case of acute eosinophilic meningoencephalitis caused by Baylisascaris procyonis in a previously healthy teenager with a history of substance abuse. Treatment included methylprednisolone; no anthelmintic drugs were administered. This case identifies a new risk factor, altered behavior related to substance abuse, and a newly described outcome of cognitive deficits for B. procyonis disease in older children.

Laboratory diagnosis and characteristics of breakthrough varicella in children.

The atypical features of varicella in vaccinated persons (breakthrough varicella [BTV]) present diagnostic challenges. We examined varicella-zoster virus (VZV) polymerase chain reaction (PCR) and immunoglobulin (Ig) M and IgG serologic test results for confirming BTV cases. Among 33 vaccinated children with varicella-like rash, we identified wild-type VZV in 58% overall and in 76% of those with adequate tissue specimens; no vaccine-type virus was found. Of the 12 subjects with PCR-confirmed BTV and acute-phase serum samples, 9 had detectable IgM, and all had highly elevated acute-phase IgG titers. Six subjects with negative PCR results had lower IgG titers and negative IgM results. Although PCR is the preferred method for laboratory confirmation of BTV, a positive serum varicella IgM test result should also be considered to be diagnostic in a suspected BTV case; however, a negative IgM test result cannot be used to rule out the diagnosis. The value of highly elevated IgG titers needs further evaluation. Larger studies are needed to confirm these results.

Chronic recurrent multifocal osteomyelitis of the spine and mandible: case report and review of the literature.

At initial presentation, chronic recurrent multifocal osteomyelitis may mimic acute hematogenous osteomyelitis; however, cultures of affected bone are sterile. Nuclear scintigraphy identifies additional foci of involvement that present concurrently or sequentially. Unlike acute bacterial osteomyelitis, chronic recurrent multifocal osteomyelitis seems unaffected by antibiotic therapy and typically responds to treatment with antiinflammatory drugs. Surgical decortication has been reported for refractory cases. The case presented here illustrates the rare involvement of the mandible after initial presentation in the spine of a 4-year-old girl and the refractory nature of the disease over 6 years despite treatment with various medical and surgical therapies.

Hepatitis B vaccination among adolescents in 3 large health maintenance organizations.

OBJECTIVE: In 1995, the Advisory Committee on Immunization Practices (ACIP) recommended routine hepatitis B (HB) vaccination of all unvaccinated 11- to 12-year-old adolescents. Little is known about the implementation of these recommendations in a managed care setting. The objective of this study was to determine the impact of ACIP recommendations on HB vaccination among adolescents in 3 managed care settings. METHODS: We assessed HB vaccination coverage among adolescents who were enrolled in 3 large health maintenance organizations (HMOs) and who turned 13 years old after the 1995 ACIP recommendations. Children who were 8 to 10 years of age during May 1993 and were continuously enrolled through December 1998 were eligible. We used the HMOs' computerized immunization tracking system to collect HB vaccination dates. The percentage of adolescents who received 3 doses of HB vaccine was determined. RESULTS: In HMOs A, B, and C, coverage levels for 3 doses of HB vaccine were 43.4%, 65.5%, and 25.7%, respectively, among 13-year-olds in 1998 compared with 26.1%, 50.4%, and 5.5% among 13-year-olds in 1996. Between the ages of 11 and 13 years, coverage rates among adolescents aged 13 in 1998 rose more than the coverage among adolescents aged 13 in 1996. The proportion of 13-year-olds in 1998 who received the first dose of HB vaccine by December 1998 was much higher at 89.6%, 65.2%, and 56.6% in HMOs A, B, and C, respectively, compared with the proportion who completed the 3-dose series (43.4%, 65.5%, and 25.7%, respectively). CONCLUSIONS: After the 1995 ACIP recommendations, HB vaccination coverage levels among 13-year-olds increased in each of the HMOs, suggesting adherence with national recommendations. Differences among the 3 HMOs may reflect differences in internal policies. More effective strategies may be needed to achieve the Healthy People 2010 goal of 90% vaccination coverage rates among adolescents.