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A 21-question survey was conducted among parents attending 4 pediatric outpatient practices to assess their knowledge, perceptions, and attitudes about fever. One hundred and ninety-seven surveys were included. Most commonly the participating parent was the mother. Parents used mainly axillary thermometers to measure child’s temperature and mentioned integers for their definition of fever, 100°F being the most frequent answer. Most parents would treat all fevers and would use alternating antipyretics. Parents had a generally negative perception of fever: only one third thought fever may have some benefit, and more than half thought there must be some risk. A positive perception of fever was associated with parental educational level but not with information by the pediatrician. There is much confusion about fever among our parents, a negative perception is prevalent, and parents seem to receive—or recall—little information from the pediatrician.

Previous studies reported the presence of Helicobacter pylori in middle ear fluid and raised a possible causal role of this bacterium in otitis media with effusion (OME). We investigated 48 children with OME (age, 7 months to 12 years) seen in New Orleans, Louisiana, and found no evidence of H pylori presence in any middle ear fluid specimen by amplification of the 16S rRNA gene. One child had H pylori detected in a stool specimen, in accordance with the low prevalence in our population. While H pylori may be significant in other countries, these findings do not support a role for H pylori in OME in our pediatric population in the United States.

Chromobacterium violaceum is a rare, potentially serious pathogen. Most clinicians have no experience with its clinical appearance or treatment. We describe a case of a child presenting with necrotizing pneumonia caused by C. violaceum. We describe case complexities, including the need for a multidisciplinary approach to diagnosis and treatment.

Background The 2017–2018 influenza season was one of the deadliest in decades, with 180 pediatric deaths, 80% among children who did not receive the vaccine. Circulating influenza strains change periodically, making it important to determine vaccine efficacy on an annual basis specifically in susceptible populations. The primary aim of our study was to estimate the effectiveness of the influenza vaccine for the 2017–2018 season. Secondary aims were to determine effect of weaning immunity and of previous season vaccination. Methods Children 6 months to 17 years tested for influenza during the 2017–2018 season at Children’s Hospital of New Orleans were included. Clinical charts were reviewed, and immunization status confirmed via the Louisiana Immunization Registry. Using a multivariable logistic regression model vaccine effectiveness (VE) was estimated by comparing vaccination status of influenza-positive vs. influenza-negative cases with the formula VE = (1 − OR) × 100%. Results 4,825 children were included; 22% of them tested positive for influenza, mostly influenza A (61.9%); 21% had received an influenza vaccine prior to illness: 14% among the influenza-positive and 23% among influenza-negative (P < 0.0001). Overall, VE for the 2017–2018 influenza season was 43% (95% CI 30, 53); 44% for influenza A and 38% for influenza B. While receiving current year (2017–2018) vaccine had the most effect, receiving the previous year (2016–2017) vaccine had additional benefit. We found no waning immunity of the vaccine for the 2017–2018 season. Conclusion Influenza VE was modest for children in the local area of New Orleans and similar to the CDC’s findings for the nation as a whole. Previous year vaccination had a small, but significant benefit and there was no evidence of waning immunity in our cohort. Ongoing national and local surveillance is important to understand the benefit of influenza vaccination. Disclosures All authors: No reported disclosures.

Background Trivalent inactivated and live attenuated influenza vaccines (IIV3 and LAIV3) have been reformulated with an extra B strain (IIV4 and LAIV4). They were licensed based on immunogenicity and their effectiveness (VE) still must be empirically tested. Methods Children 1–17 years tested for influenza during 2013–16 were included and their immunization status verified. They were considered vaccinated if received ≥1 dose of an influenza vaccine ≥10 days before evaluated for a respiratory episode. Age-groups were classified as 1–4 years or 5–17 years. VE was estimated by comparing vaccination status of influenza-positive versus influenza-negative cases. Results 6779 children were enrolled in the three seasons. Overall, 27.2% received an influenza vaccine (87.1% IIV3 or IIV4 and 12.9% LAIV4), and 15.6% tested positive for influenza (77.9% A). IIV3 was predominantly used in 2013–14 and IIV4 in 2014–15 and 2015–16. IIV3 and IIV4 had comparable VE over the three seasons (60%, 57% and 53%) and performed similarly against influenza A and B and both age-groups. LAIV4 performed poorly for influenza A (15%, 37% and 48%) but better for influenza B (100%, 56% and 100%), especially among children 5–17 years of age with VE = 100% (95%CI: 55, 100). Conclusions Influenza vaccination showed modest but consistent effectiveness over the years. The switch from IIV3 to IIV4 did not affect VE. LAIV4 did not perform as well as IIVs, yet it improved over the years and was particularly good protecting older children against influenza B. These results emphasize the regional nature of influenza and the need for local surveillance.

Osteomyelitis of the clavicle is a rare entity with a broad differential diagnosis and high potential for complications if not diagnosed promptly and treated appropriately. The threshold for surgical intervention should be low to prevent osteonecrosis and bony resorption. In addition, although rare, life-threatening complications have been reported. This report describes primary osteomyelitis of the clavicle that was diagnosed in a 22-month-old girl on her third clinical evaluation after 4 days of symptoms. She presented to a children's tertiary care emergency department with fever and acute pain and swelling of her right shoulder and arm. The diagnosis was confirmed through clinical, laboratory, and imaging studies including ultrasound; these revealed subperiosteal abscess formation, which may have developed in part as the result of a delayed diagnosis from the 2 prior emergency department visits. The patient was treated initially with intravenous antibiotics and underwent therapeutic as well as diagnostic needle-guided tissue aspiration under ultrasound guidance. This ruled out malignancy but was not curative, and the subperiosteal abscess recurred within 24 hours, prompting formal operative irrigation and debridement. The patient was seen for 12-month follow-up and has had no complications or evidence of recurrence. This case emphasizes the need for a high index of suspicion to prevent diagnostic delays as well as the importance of a low threshold for surgical debridement to minimize the potential for complications that could prolong the treatment course. [ Orthopedics. 2016; 39(4):e760–e763.]

John J Hawkshead III,1 Russell B Van Dyke,2 Susan E Hassig,3 Larry S Webber,4 Rodolfo E Begue5 1Merck & Co, CORE Hospital Specialty Group, Rahway, NJ, 2Department of Pediatrics, Tulane University School of Medicine, 3Department of Epidemiology, 4Department of Biostatistics, Tulane University School of Public Health and Tropical Medicine, 5Department of Pediatrics, Louisiana State University Health Sciences Center, New Orleans, LA, USA Background: Pediatric Candida infections are associated with worse clinical outcomes and increased costs. Yet, it is not definitively known if particular species are associated with more severe illness. Differential risk factor exposures among the species group may also exist. We aimed to determine whether certain Candida species are more strongly associated with worse outcomes, and whether certain risk factors more strongly predispose patients to infection with certain species. Methods: Microbiology lab records from patients seen from 2003 to 2010 at an urban children's hospital were reviewed for invasive or disseminated Candida infections. Data on measures of disease severity/outcome and risk factors were abstracted and analyzed to determine differences associated with various Candida species. Results: Exactly 106 cases of infection were analyzed. Non-albicans species were associated with a significantly longer length of stay postdiagnosis (P=0.03), as well as longer treatment (P=0.02). Candida albicans was associated with a higher number of antihypotensive medications required (P=0.03) and length of mechanical ventilation postdiagnosis (P=0.05). Candida tropicalis was associated with the highest mortality (45.5%). Hypotension, which was found to be significantly associated with concurrent infection, was significantly associated with increased risk of mortality (odds ratio =5.85, P=0.005). Initial choice of antifungal therapy was not associated with differences in eventual patient mortality. Multivariate logistic regression modeling revealed a trend toward C. albicans infection in patients receiving antineoplastic chemotherapy and non-albicans infection in patients with >96 hours mechanical ventilation. Conclusion: Interspecies differences may exist for Candida in terms of disease severity and risk factors. Underlying morbidity and the role of concurrent infections may play a key role in poor outcomes. Keywords: Candida, disseminated, pediatric, severity, risk factors, fungemia, antifungal, coinfection

Background Quadrivalent live attenuated influenza vaccine (LAIV4) was not recommended for use in the United States for the 2016–2017 and 2017–2018 influenza seasons based on US observational studies of vaccine effectiveness (VE) from 2013–2014 to 2015–2016. We pooled individual patient data on children aged 2–17 years enrolled in 5 US studies during these 3 influenza seasons to further investigate VE by vaccine type. Methods Analyses included 17,173 children enrolled in the US Department of Defense Global Laboratory-based Influenza Surveillance Program, US Influenza Vaccine Effectiveness Network, Influenza Incidence Surveillance Project, Influenza Clinical Investigation for Children, and a Louisiana State University study. Participants’ specimens were tested for influenza by reverse transcription-polymerase chain reaction (RT-PCR), culture, or a combination of rapid antigen testing and RT-PCR. VE was calculated by comparing odds of vaccination with either inactivated influenza vaccine (IIV) or LAIV4 among influenza-positive cases to test-negative controls and calculated as 100 × (1 − odds ratio) in logistic regression models with age, calendar time, influenza season, and study site (random effect). Patients were stratified by prior season vaccination status in a subanalysis. Results Overall, 38% of patients (N = 6,558) were vaccinated in the current season, of whom 30% (N = 1,979) received LAIV4. Pooled VE of IIV against any influenza virus was 51% (95% CI: 47, 54) versus 26% (95% CI: 15, 36) for LAIV4. Point estimates for pooled VE against any influenza by age group ranged from 45% to 58% for IIV and 19% to 34% for LAIV4 during the 3 seasons (Figures 1 and 2). Pooled VE against influenza A(H1N1)pdm09 was 67% (95% CI: 62, 72) for IIV versus 20% (95% CI: −6, 39) for LAIV4. Pooled VE against influenza A(H3N2) was 29% (95% CI: 14, 42) for IIV versus 7% (95% CI: −11, 23) for LAIV4, and VE against influenza B was 52% (95% CI: 42, 60) for IIV and 66% (95% CI: 47, 77) for LAIV4. VE against influenza A(H1N1)pdm09 was lower for LAIV4 versus IIV across all strata of prior season vaccination (Figure 3). Conclusion Consistent with individual studies, our pooled analyses found that LAIV4 effectiveness was reduced for all age groups against influenza A(H1N1)pdm09 compared with IIV. This result did not vary based on prior vaccination status. Disclosures H. Caspard, AstraZeneca: Employee, Salary.

Background: In 2006 a rotavirus (RV) vaccine (Rota Teq ® ) was licensed for routine childhood immunization in the US. The aim of the present study was to track changes in RV hospital visits and to monitor circulating RV genotypes as vaccination was introduced into New Orleans, Louisiana. Methods: From July 2005 to June 2009, RV-positive stool specimens were systematically collected, viral RNA was extracted and subjected to semi-nested multiplex Reverse-Transcription PCR with primers specific for the gene 9 (G) types G1, G2, G3, G4, G9, and the gene 4 (P) types P(4), P(6), P(8), P(9) and P(10). Clinical records of RV-positive children were reviewed. Results: As RV-vaccination was introduced, there was a decrease in the rate of RV-positive cases (per 1,000 hospital visits) from 3.82 to 0.73. A change was noted in the prevailing genotypes, from a predominance of G1P(8) strains to a predominance of G3P(8). Most affected children were unimmunized. Sequence analysis of gene 9 and gene 4 showed that the circulating strains remained relatively stable over the years studied in this project. Conclusion: In New Orleans, G3P(8) is becoming a predominant strain of RV. The cause of this change observed has not been determined. It is unclear whether this phenomenon represents natural variation or it is caused by introduction of vaccines.

A vaccine could alleviate major morbidity and mortality associated with Helicobacter pylori infection. We immunized BALB/c mice with 3 doses of a protein or DNA vaccine based on H pylori urease B. Protein alone was immunogenic even after the first dose, whereas DNA did not elicit antibodies after 3 doses. DNA preceding protein (D-P-P) appeared to blunt the response to protein, whereas DNA following protein (P-D-D) shifted from a predominantly T helper 2 (Th2) profile to a balanced Th1:Th2 profile. These preliminary findings may have important implications for the development of an H pylori vaccine.

Background. We previously REPORTED that mice with diabetes and short-term Helicobacter felis infection had an increase in glycated hemoglobin (HbA1c). Here we report the effect of long-term infection. Materials and Methods. Six-week-old C57BL/6 mice were injected with streptozotocin to induce diabetes and started on daily insulin. Following streptozotocin injection, animals were paired according to their HbA1c values and randomized to orally receive either H. felis or culture medium alone. Weight and HbA1c were monitored monthly for 6 months. Results. Thirty animals corresponding to 15 pairs were included in the study. H. felis-infected diabetic mice developed significantly more gastritis than uninfected animals. Sixteen mice died during the observation period. As compared to uninfected animals, infected mice died more frequently (40% versus 67%, p = .14) and earlier (160 versus 61 days, p = .20); both variables combined showed that H. felis infection significantly decreased the chances of survival during the study period (p = .045). In addition, infected mice showed a trend for higher increase in their HbA1c (0.97 ± 2.5% versus – 0.22 ± 3.0%; p = .21) and lower weight gain (2.0 ± 3.4 g versus 2.9 ± 2.0 g; p = .15) than uninfected mice. Conclusion. Long-term H. felis infection had a deleterious effect in mice with streptozotocin-induced diabetes resulting in increased mortality. If the same phenomenon occurs in humans this could lead to interventions to improve the long-term outcome of patients with diabetes.

Helicobacter pylori infection has been described in association with increases in glycated hemoglobin (HbA 1c ) levels in patients with type 1 diabetes. The purpose of the present study was to use an animal model of Helicobacter infection to test, under controlled conditions, the hypothesis that infection is associated with high HbA 1c levels. Diabetes was induced in C57BL/6 mice by administration of streptozotocin, and the mice were orally inoculated with H. felis. Six weeks after inoculation, infected mice (n = 10) showed gastritis scores significantly greater (P = 01) than those of uninfected mice (n = 10). HbA 1c levels were significantly higher in infected mice with gastritis (11.6%; n = 6) than in infected mice without gastritis (8.4%; n = 4) or uninfected mice (7.6%; n = 10). It was concluded that gastritis induced by H. felis is associated with increased HbA 1c levels in the mouse model of streptozotocin-induced diabetes.

Infection by Baylisascaris procyonis is an uncommon but devastating cause of eosinophilic meningitis. We report the first case-patient, to our knowledge, who recovered from B. procyonis eosinophilic meningitis without any recognizable neurologic deficits. The spectrum of illness for this organism may be wider than previously recognized.

Objective: To describe the implementation of a program for the use of palivizumab in a general pediatrics office and evaluate adherence to the 2009 American Academy of Pediatrics (AAP) guidelines. Methods: Pediatricians in a large practice were educated in the diagnosis and management of bronchiolitis, with specific attention to the AAP’s palivizumab administration guidelines. During the 2009–2010 and 2010–2011 respiratory syncytial virus seasons, children were systematically identified and enrolled for palivizumab administration. Indication for administration was determined by gestational age, age at the beginning of the respiratory syncytial virus season, pertinent diagnoses, and presence of risk factors. Results: In the 2009–2010 season, 161 children were enrolled to receive palivizumab, 86 of whom (53%) conformed with AAP guidelines. In contrast, in 2010–2011, a total of 85 children were enrolled to receive palivizumab, and 73 (86%) conformed with the guidelines. As a consequence, the total cost of palivizumab (US $: 511 559 vs 1 500 670) and the cost per child (US $: 6018 vs 9438) were lower in 2010–2011 than in 2009–2010. However, of the children selected within the AAP guidelines, only 29% received the appropriate number of doses, whereas 62% and 9% received fewer or excessive doses, respectively; these findings were similar for the 2 seasons. Conclusions: In a primary practice, use of palivizumab outside of the AAP guidelines was frequent and manifested as inadequate indications or inadequate number of doses. The former improved with education and standardization of care (suggesting provider problems), while the latter did not (suggesting system problems). Additional interventions are required.

An outbreak of influenza A pandemic (H1N1) 2009 occurred among campers and staff at a summer camp attended by children with hematologic and oncologic conditions. The overall attack rate was 36% and was highest among children and adolescents (43%), persons with cancer (48%), and persons with sickle cell disease (82%).

OBJECTIVES: Pentavalent rotavirus (RV) vaccine (RV5) was licensed in 2006 and recommended for routine childhood immunization. A significant decrease in the number of RV hospitalizations has been described. The objective of this study was to evaluate the effect of RV5 on acute gastroenteritis (AGE) seen in a primary practice. METHODS: In July 2004, surveillance was initiated among children who were younger than 5 years and seen in a large pediatric practice in New Orleans for those who presented AGE, as determined by International Classification of Diseases, Ninth Revision codes. Primary care physician office visits, emergency department visits, and hospital admissions were identified by review of records. RV testing was performed only on those who were seen at the hospital. RESULTS: Approximately 16 000 children who were younger than 5 years were followed in the practice during each year. For 2006–2007, 2007–2008, and 2008–2009, 11.1%, 40.3%, and 45.6% of age-eligible children, respectively, received ≥1 dose of RV5. As compared with 2004–2005 (before RV5), in 2007–2009, there was a significant decrease in all-cause AGE office visits (23%) and hospitalizations (50%). RV-positive cases (emergency department visits or hospitalizations) decreased by 67%. The decrease in RV-positive cases was more evident among children who were younger than 2 years (81%), with a strong trend among those who were aged 2 to CONCLUSIONS: Increased use of RV5 in a pediatric practice was associated with fewer AGE office visits and hospitalizations. The reduction was specific for RV-positive AGE and seen among children who were targeted for immunization as well as older groups, suggesting a herd-immunity effect.

Because of the high prevalence of Helicobacter pylori infection and the morbidity and mortality associated to the disease, development of a preventive vaccine has become a priority. To this goal, we produced recombinant H. pylori urease B (rUreB) and tested its immunogenicity in BALB/c mice when administered as 3 doses (week 0, 4 and 6) by either parenteral (intramuscular) or mucosal routes (intragastric, intranasal, intrarectal) and with the use of various adjuvants (none, CpG, alum or Freund's). The intramuscular route was more immunogenic than any mucosal route; of the mucosas, only intranasal induced modest levels of serum IgG. All adjuvants improved the seroresponse to plain rUreB and, of them, Freund's and alum were equally good and better than CpG ODN 1826. Stool IgA was barely detected by any immunization strategy.

Vaccines are traditionally tested under the optimal conditions of clinical trials (efficacy). However, their public health impact is better assessed under the real conditions of a clinical practice (effectiveness). The authors aimed to estimate the effectiveness of a rotavirus vaccine (rhesus rotavirus vaccine-tetravalent (RRV-TV)) to prevent rotavirus-related hospitalization among children

We previously reported that children with diabetes and Helicobacter pylori infection had higher levels of glycated hemoglobin (HbA1c) than uninfected peers. We sought to determine whether eradication of the infection could decrease their HbA1c level.Eight children with type 1 diabetes and H. pylori infection (cases) were treated to eradicate the infection. Cases were matched (2:1) with uninfected diabetic children (controls), and their HbA1c levels were monitored.As previously described, cases started with higher HbA1c values than controls. More than 2 years after treatment, cases showed a decreasing trend and controls an increasing trend in HbA1c values. At the end of the study, cases and controls had comparable HbA1c values.These data suggest that eradication of H. pylori infection in patients with type 1 diabetes might be associated with better control of glycemia.

Correspondence: Lorna M Seybolt Children’s Hospital, Infectious Diseases, ACC #2316, 200 Henry Clay Avenue, New Orleans, LA 70118, USA Tel +1 504 896 9820 Fax +1 504 894 5137 Email lseybo@lsuhsc.edu Abstract: Until recently, rotavirus was the most common cause of diarrhea in infants and young children with over 100 million cases and 400,000 deaths every year worldwide. Yet, its epidemiology is changing rapidly with the introduction of two rotavirus vaccines in the mid 2000s. Both vaccines were shown to be highly efficacious in prelicensure studies to reduce severe rotavirus disease; the efficacy being more pronounced in highand middle-income countries than in low-income countries. Herd immunity – the indirect protection of unimmunized individuals as a result of others being immunized – was not expected to be a benefit of rotavirus vaccination programs since the vaccines were thought to reduce severe disease but not to decrease virus transmission significantly. Postlicensure studies, however, have suggested that this assumption may need reassessment. Studies in a variety of settings have shown evidence of greater than expected declines in rotavirus disease. While these studies were not designed specifically to detect herd immunity – and few failed to detect this phenomenon – the consistency of the evidence is compelling. These studies are reviewed and described here. While further work is needed, clarifying the presence of herd immunity is not just an academic exercise but an important issue for rotavirus control, especially in lower income countries where the incidence of the disease is highest and the direct protection of the vaccines is lower.