LETTERS

LETTERS

Obstacles to hepatitis A vaccination

I enjoyed "A progress report on hepatitis A vaccination" (December)but do not agree that the "four main obstacles" to universal vaccinationthe authors describe are difficult to overcome:

• "The vaccine is not licensed for use in infants." Policy decisions about immunization do not have to wait until we have these approvals or until a combined hepatitis A­hepatitis B vaccine is developed. We started Hib immunization with the PRP vaccine at 2 years of age in 1985. After the conjugate vaccines were licensed for 18-month-olds, we started seeing a decrease in Hib disease in infants. Although HAV is not Hib, there is no reason to believe that the same herd immunity would not apply. There are data to suggest that in communities with high rates of HAV infection, vaccination of children aged 2 to 12 years interrupts or prevents outbreaks.
• "Many parents and health-care providers will oppose adding yet another injectable vaccine to the infant vaccination schedule." Most objections about multiple shots are from health-care workers, who project their own sense of discomfort and feeling of guilt. Most parents, when given the choice of a good and safe vaccine, will consent to more shots for their children. Consider, for example, parental acceptance of two shots for DTaP with a separate shot for Hib instead of H-DTP as a single dose and of IPV over OPV. In the Northern California Kaiser Permanente conjugate pneumococcal/meningococcal vaccine trial, we succeeded in recruiting 39,000 infants, some of whom received five shots per visit. Because the public perceives that hepatitis is a "dreadful disease," I bet that many parents would line up their children for the HAV vaccine.
• "We don't know if universal vaccination is cost-effective." Preliminary data indicate that in some states where HAV incidence is about twice the national average, a program of two doses of HAV vaccine at a cost of $30 per individual and 75% effective coverage would be quite cost-effective: $203 saved in direct medical costs for each prevented case. This compares very favorably with the cost-effectiveness of other recently licensed vaccines, such as varicella and rotavirus.
• "How long the vaccine is protective is unknown." It is premature for the authors to speculate that it is "likely that if a booster is necessary it could be given at the same time as the MMR booster." Based on the data we now have on duration of antibody levels, I would predict that if a booster is necessary, it would be more reasonable to target preteens or young adults.

I sense great acceptance from the general public for the presently availablevaccine and believe that the lack of resources at the public health levelare the main deterrent to routine HAV immunization.

Chinh Le, MD
Kaiser Permanente Medical Group in Northern California
Santa Rosa, CA

The authors reply: We appreciate Dr. Le's comments on our article andapplaud his optimism over the potential implementation of universal vaccination.We wish we could be so confident that the four obstacles we presented couldbe overcome so easily. We agree that as with the Hib conjugate vaccines,universal administration of HAV after infancy would be associated with diseaseprevention in immunized children and unimmunized contacts. HAV is currentlylicensed for use at 2 years of age, not at 15 to 18 months when other vaccinesare routinely administered, however. Another visit to administer HAV at24 months would result in greater health-care costs and would likely bea barrier to immunization.

We also concur that most families will agree to multiple injections ofvaccines if they prevent disease and improve the safety of the vaccinesadministered. Unfortunately, the reluctance of health-care providers toadminister multiple antigens still remains an issue.

We encourage Dr. Le to document in the literature the widespread acceptanceof multiple injections in the pivotal Streptococcus pneumoniaeconjugatevaccine studies and to suggest ways to enhance parental acceptance. He andhis colleagues have been leaders in vaccine evaluation and implementationand continue to be models for the rest of us to emulate.

We have been unable to document complete cost-effectiveness studies inthe literature and did not perform such studies ourselves. We would welcomesuch data and hope that the preliminary data Dr. Le mentioned soon willbe available and will be used to promote universal vaccination.

Current studies suggest that when vaccine is administered to older childrenand adults, protection persists for at least a decade. If the studies ofvaccine administration in infants confirm these results, we would concurwith Dr. Le that a booster might not be needed until adolescence.

Again, we thank Dr. Le for his comments and encourage him to continuehis important work in the promotion of safe and effective vaccines.

Neil Harris
Kathryn M. Edwards, MD
Nashville, TN

Don't knock PNPs

I am writing in response to Dr. McMillan's editorial, "Who shouldprovide health care for children?" (December). As a future pediatricnurse practitioner, I am disheartened to read yet again the words of a pediatricianwho has ascertained that she and her colleagues are the best health-careproviders for children, without adequate scientific proof to back up theseclaims.

I look forward to a day when pediatricians are secure enough in theirroles to no longer feel threatened by mid-level providers who provide excellentcare to children. People in all these professions need to work togetherto improve the health and lives of all children and not waste valuable moneyand resources proving who is "superior." PNPs do not claim tobe "superior," but we can make a valuable contribution to thefield of pediatrics. Pediatricians should honor this, instead of cuttingus down as often as possible.

Heidi C. Clark, RN
Washington, DC

The author replies: I deeply regret having left Ms. Clark or other readerswith the impression that my editorial was meant to demean the role of pediatricnurse practitioners. I have nothing but respect for the skills of the PNPswith whom I have worked. Early in my career, I was the Co-Director of anurse practitioner program. The other Co-Director was a PNP who is one ofthe most capable clinicians I have known. PNPs are important and valuedcolleagues in providing medical care to children, in broadening the arrayof services available in offices, clinics, and inpatient setting, and inmedical education.

It is important, however, that the community of pediatricians clarifyfor itself and for the public what distinguishes us from others who providemedical care for infants, children, adolescents, and young adults. Nursepractitioners probably should do the same for themselves. The goal is notto downplay the importance or the expertise of PNPs or other providers,but to be certain that pediatricians are who we think we are--that the trainingwe receive really does prepare each of us to provide care for young peoplefrom birth to 21 years and for the entire range of medical problems of peoplein this age group.

We would also like to be able to demonstrate that the services we providehave benefits. I agree with Ms. Clark that doing this requires "adequatescientific proof." I do believe that at times it is appropriate toplace the medical care of pediatric patients in the hands of a pediatricianrather than a nurse practitioner. What we're lacking is data that demonstratewhat those circumstances are, and why.

Julia A. McMillan, MD
Baltimore, MD

Questions on strep throat

Thank you for "Strep throat: Weighing the diagnostic options"(November), which was informative. It did raise several questions, however.

• Should anterior cervical tender adenopathy be considered a sign of group A b-hemolytic streptococci?
• I strongly believe that a culture should be done because of clinical signs of the disease and that all symptoms are only supportive. But what about the patient with a positive culture who has a sore throat with fever but none of the signs of pharyngitis or tonsillitis? Does this child require any treatment? Should he or she be labeled a carrier?

H. Tsai, MD
Brooklyn, NY

The authors reply: We agree that tender anterior cervical adenopathyshould be included as a sign of infection caused by group A b-hemolyticstreptococcus. The presence of both signs and symptoms of "strep throat"enables the practitioner to identify more readily the child infected withGABHS. The signs are not specific for streptococcal pharyngitis, however.Tender anterior cervical nodes may be observed with other causes of pharyngitisas well. Consequently, a throat culture always should be performed.

With regard to the child with pharyngitis but no clinical signs of disease,we agree that a throat culture is in order. We would initiate appropriateantimicrobial therapy if the throat culture was positive for GABHS. Thechild may indeed be a carrier, however, and a second culture performed whentreatment is concluded and symptoms have resolved would help distinguishthe carrier state from true infection. If the second culture is also positivefor the same serotype of GABHS, the child is a carrier. It may be appropriateto try to eradicate the carrier state with clindamycin.

Raymond Pitetti, MD
Ellen Wald, MD
Pittsburgh, PA

Pampers for 5-year-olds?

I've been seeing a TV advertisement for Pampers designed to fit a 4-to 5-year-old. A well-known developmental pediatrician appears on the screento tell millions of people that parents should support a child's wish touse diapers until he or she is "ready" to be toilet trained.

This brings to mind a scenario: A 4- or 5-year-old wearing his new Pampersand holding a bottle is playing on the keyboard of the family's PC or competentlyoperating the remote control of the TV. Is this what we want for futuregenerations--to teach complex technological tasks at 15 to 24 months ofage but leave toilet training until the child is "ready"? If parentsput a diaper on a 4-year-old, they are providing a strong stimulus to gopotty in the diaper. It is unimaginable how a child even will consider notgoing in the diaper unless the diaper is taken off.

The key here is that kids learn by watching what their caretakers do.And while they see parents using remotes and computers, they do not seethem on the potty. I suggest ritualistically taking the child into the bathroomwhen the parent uses the toilet, taking off the child's diaper, and lettinghim watch what happens. It won't take long for the child to be toilet trained.This is the process used in the Third World where there are no diapers andthe average child is potty trained--just by watching--by the time he iswalking.

Amar Dave, MD
Ottawa, IL

Correction

The picture credit for Figure 11 in "Skin lesions that mimic abuse"(January) should have contained the following additional citation: ScalesJW, Fleischer AB, Jr, Krowchuk DP: Bullous impetigo.Archives of Pediatricand Adolescent Medicine 1997;151:1168.

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