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Seasonal Influenza:
This seasonís first influenza isolates [influenza A
(H1N1)] were submitted by a pediatrician
participating in the County sentinel provider
surveillance program for influenza-like illness.
Children play a major role in influenza transmission
and pediatricians are on the front line to detect
influenza activity in our County. We encourage
health care providers to participate in influenza
surveillance, which just takes a few minutes a week.
In return, sentinel providers receive specimen kits for
viral isolation, rapid test kits, weekly summaries of
local influenza activity, and subscriptions to MMWR
and Emerging Infectious Diseases journals. The most
consistent reporters also receive medical handbooks
from the State. For more information, contact
Michele Cheung, MD MPH at mcheung@ochca.com or
714-834-7729.
To receive our influenza newsletter, Eye on
Influenza, email epi@ochca.com or call 714-834-
8180. Issues are also posted.
All patients who present to a healthcare setting
with fever and respiratory symptoms should be
managed according to CDCís recommendations for
Respiratory Hygiene and
Cough Etiquette.
Influenza Vaccine:
New this season for children: Influenza vaccination
recommendations have expanded to include all
children 6-59 months of age, as well as the
previously recommended groups with chronic health
conditions or on long-term aspirin therapy.
Household contacts and caregivers of children 0-59
months of age or of persons with chronic health
conditions should also be vaccinated annually.
The CDC recommends that all healthcare providers
(HCP) receive annual influenza vaccination and that
influenza vaccination be offered to HCP at the work
site at no cost. CDC also recommends that HCP who
decline influenza vaccination be asked to sign a
declination form.
For
more information, see Influenza Vaccination of
Health-Care Personnel (2/24/06 MMWR
Recommendations and Reports).
Beginning January 1, 2007, JCAHO will be including
influenza vaccination of HCP in accreditation
requirements. For more information.
West Nile Virus:
West Nile Virus (WNV) season is winding down. This
year, Orange County reported 6 WNV infections (2
West Nile Fever, 3 West Nile Neuroinvasive Disease,
and 1 asymptomatic blood donor). This is less than
in 2005 (17 WNV infections) and 2004 (64 WNV
infections). For a summary of WNV in Orange County
2004-2006, see our West Nile File newsletter (volume
2, issue 13).
Avian and Pandemic Influenza:
Clinicians should maintain a high index of suspicion for
influenza A (H5N1) in patients with fever and
respiratory symptoms arriving or returning from H5N1
affected countries. For an up-to-date list of areas with H5N1 in birds or
humans. Please consult Orange County
Epidemiology at 714-834-8180 for diagnostic and
infection control recommendations.
For our Eye on Influenza newsletter, which
includes updates on avian and pandemic influenza,
contact us at 714-834-8180 or epi@ochca.com.
For more information on any of the above topics,
please call Epidemiology at 714-834-8180.
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Recognizing the Signs of Late Onset Hearing Loss
in
Infants and Young Children, Sudeep Kukreja,
M.D.
With 39 out of 50 states mandating universal
newborn hearing screening (UNHS), and newborn
hearing screening data being collected from 40
states, it would be easy to assume that the
identification of permanent childhood hearing loss is
guaranteed. Yet, the fact is that some childhood
hearing losses have a later onset and will not be
identified through newborn screening methods.
What is the prevalence of childhood hearing loss?
Current UNHS statistics indicate an overall
hearing loss prevalence rate of 1-2 per 1000 at
birth. These prevalence statistics are consistent
across the US and are not dependent on the
particular hearing screening method being used.
Statistical information about the prevalence of
hearing loss in older children is difficult to find and
interpret for a number of reasons. Late onset or
progressive hearing loss can be due to hereditary
factors, infection, trauma, noise exposure or
teratogens. Studies also vary in how ěsignificant
hearing lossî is defined. As a result, the prevalence
of late onset hearing loss is not well defined. In
general there is a trend toward increasing rates of
hearing loss as children get older.
Can newborn hearing screening miss hearing loss
that is present at birth? It is possible for some
children to have a mild or minimal hearing loss at birth
and pass universal hearing screening. This is due, at
least in part, to the underlying assumptions about
newborn hearing screening. Any type of universal
screening program needs to achieve a low false-
alarm rate and a high ěhitî rate. The goal for UNHS
is that few children are referred for additional, more
expensive testing who do not need it and those who
are referred have a high likelihood of having hearing
loss. To meet these requirements, current UNHS
methods may not identify children with mild hearing
losses. If no further audiological monitoring is being
completed within the childís medical home, the result
could be late identification of milder degrees of
hearing loss.
In some instances, mild hearing loss that is present
at birth may progress to more severe hearing loss
after the child goes home from the hospital. Rapidly
progressive hearing loss can be associated with
several congenital conditions, including
Cytomegalovirus (CMV) and Large Vestibular
Aqueduct (LVA) as well as some genetically inherited
losses.
What are the most common causes of late-onset
hearing loss? The major categories of late-
onset loss are acquired, structural, and genetic.
Acquired: Among acquired late-onset
losses, congenital CMV (both symptomatic and non-
symptomatic) is the most common and accounts for
around 1/3 of all hearing loss in children. Hearing
loss associated with CMV may be both late onset and
progressive within the first years of life. Even
asymptomatic congenital CMV infection carries an
increased risk of hearing loss. Hearing loss
prevalence rates of 7-15% in asymptomatic cases
have been reported. Congenital symptomatic CMV
infection carries greater risk for hearing loss and a
higher percentage of children with active CMV
symptoms at birth have hearing loss identified
through UNHS, with further progression reported
within the first 2-3 years (Fowler, et al 1997; Barbi,
et al 2003). Other childhood illnesses may also
cause hearing loss. These include viral or bacterial
meningitis, mumps and other viral infections that
cause a high fever or central sequelae. Head trauma
with skull fracture is one type of traumatic late-
onset loss. Chemotherapeutic agents containing
platinum, such as cisplatin, are among the best
known ototoxic medications.
Structural: Structural causes of late-onset
hearing loss may occur with a number of syndromes.
Structural deformities of the cochlea such as LVA
and Mondini malformation are congenital but not
always related to a specific syndrome. Cochlear
malformations affect hearing differently in different
children. Some hearing losses may occur earlier and
others may not present until later childhood.
Structural malformations of the inner ear are
associated with sudden and extreme progression and
fluctuation of hearing.
Genetic: Genetic causes of late-onset
hearing loss may be syndromic or non-syndromic. Full explanations of specific syndrome
characteristics can be found online on OMIM, the
Online Mendelian Index in Man.
Syndromic losses include:
Non-syndromic losses include: What are the main risk factors associated with
late-onset loss?
How can Primary Care Providers monitor for late-
onset loss? Performing surveillance and
screening within the medical home is the best way to
monitor infants and young children for late-onset
hearing loss. Primary Care Providers are the medical
providers who see the child most often and are able
to review auditory skill development and
developmental milestones at well-child visits. An
immediate referral for audiological evaluation is
warranted if parents express concerns about a childís
hearing responsiveness or speech and language
development. For young children and infants under 3
years of age, typical in-office hearing screening
methods are not effective and a referral to a
pediatric audiologist is recommended. All children
with an identified risk factor for late-onset hearing
loss should receive a comprehensive audiological
assessment as soon as behavioral testing can be
completed. Even if that child has passed newborn
screening and no parental concerns have been
expressed, a comprehensive evaluation can identify
subtle or progressive losses which require remediation
and monitoring. A combination of electrophysiological
and developmentally-appropriate behavioral tests can
be used to test hearing at any age and any
developmental level.
Early identification of hearing loss leads to better
speech, language and learning outcomes for
children. Knowledge of the risk factors for late-onset
hearing loss and continued vigilance in screening,
monitoring and referral are vital. The goal is to
insure that the listening and learning needs of all
children are met.
References:
Barbi, M., Binda, S., Caroppo, S., Abrosetti, U., Corbetta, C., Sergi, P. (2003). A wider role for congenital cytomegalovirus infection in sensorineural hearing loss. Pediatric Infectious Disease Journal, 22 (1);39-42. Fowler, K., McCollister, F., Dahle, A., Boppana, S., Britt, W., Pass, R. (1997). Progressive and fluctuating sensorineural hearing loss in children with asymptomatic congenital cytomegalovirus infection. The Journal of Pediatrics, 130(4);624-630. |
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The American American Academy of Pediatrics,
California District (AAP-CA) applauds the action
California Health and human Services Secretary Kim
Belsche took with concurrence from the Governor, to
grant a six-week exemption from restrictions
regarding the administration of thermosal-containing
vaccines to children under three.
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In 2007 the AAP-CA will once again hold the Annual
Legislative Day in conjunction with CMA's Legislative
Day. Kris Calvin, AAP-CA Executive Director, will be
holding a legislative advocacy training and AAP-CA
will be organizing legislative visits on our top issues
for next year.
Legislators and their staff listen to pediatricians and
pediatric residents who take the time to meet face-
to-face with them to educate them about the most
critical legislative issues facing children and
pediatrics today. Please mark April 24th, 2007 as one
day away from your practice that will profoundly
affect you and your patients.
Agenda and registration information will be sent out
in early 2007.
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The Department of Health & Human Services (HHS)
Agency for Healthcare Research and Quality (AHRQ),
in partnership with the American Academy of
Pediatrics (AAP), October 27 released Pediatric
Terrorism and Disaster Preparedness: A Resource for
Pediatricians. The resource is intended to
increase awareness about the unique needs of
children and encourage collaboration among
pediatricians, state and local emergency response
planners, health care systems, and others involved in
planning and response efforts for natural disasters
and terrorism incidents.
Development of the resource, which is
available online was funded by AHRQ, the Office
of Public Health Emergency Preparedness, and the
Health Resources and Services Administration. AHRQ
has several related resources to help clinicians,
policy makers, and the public address the special
needs of children in emergency situations, including
the report,
Pediatric Anthrax: Implications for Bioterrorism
Preparedness and the video
Decontamination of Children: Preparedness and
Response for Hospital Emergency Departments.
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Deborah Monfea
California Chapter 4, American Academy of Pediatrics
email:
ca4aap@sbcglobal.net
phone:
714/971-0695
website:
http://www.aapca4.org
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