1. 5th Annual Advocacy Project: ImmuneWise Section on Medical Students, Residents, and Fellowship Trainees 2009-2010

3. Case Presentation

4. 4 year old female is on the illness clinic schedule Her mom reports 2 days of fever and decreased energy level

5. Case Presentation Review of Systems –Temp to 102°F –Mild headache –Eye redness –Mild congestion –Non-productive cough –No GI complaints –No rash PMHx –Healthy –Due for 4-5 year old immunizations SHx –Lives with parents –No known sick contacts –Recent travel to Disney World (about 10 days ago)

6. Case Presentation - Exam General: Cooperative, NAD but appears ill HEENT: PERRL, bilateral conjunctival erythema and watery eyes, nares patent, MMM without lesions, neck supple, no lymphadenopathy Chest: CTA bilaterally, no wheeze/rales/rhonchi; RRR, no murmur/rub/gallop Abd: Active BS, soft, non-tender, no HSM Skin: No rash or lesions noted

7. Case Presentation Diagnosed with a viral upper respiratory infection Supportive care was discussed with the patient’s mother

8. Case Presentation The 4 year old returns the next day with a new rash… Exam is unchanged except for a blotchy, blanching erythematous maculopapular rash on her face and neck

9. Differential Diagnosis - Discussion

10. Management

11. Measles Epidemiology Humans are the only natural host Transmitted by direct contact with droplets –may contract from airborne droplets too Most common in preschool and early school-aged children with a late winter peak Vaccine licensed in 1963 Vaccine failure rate of 5% in those with only a single dose

12. Measles Epidemiology

14. Measles Clinical Presentation Incubation period of 8-12 days Symptoms and signs include: –Fever, malaise, cough –Conjunctivitis, coryza, +/- photophobia –Koplik spots on soft palate (often occur before the rash and are diagnostic) –Rash, usually day 2-3 of illness Contagious for 1-2 days before onset of symptoms until ~4 days after rash appears

15. Measles Clinical Presentation

16. Measles Diagnosis Serum sample positive for measles IgM antibody on initial presentation –Sensitivity varies - low in first 72 hours of rash –If the initial test is negative, consider repeating after the rash is present > 72 hours Significant rise in measles IgG in paired acute – convalescent samples Measles RNA in blood, throat, nasopharyngeal or urine samples (by PCR)

17. Measles Complications Complications include: –Otitis media –Croup or bronchopneumonia –Diarrhea Severe complications: –Acute encephalitis in 1/1000 cases –Death in 1-3/1000 cases Usually due to respiratory or neuro complications –Subacute sclerosing panencephalitis (SSPE) Degenerative CNS disease

18. Measles Treatment Supportive care Vitamin A –Give if vitamin A deficiency is endemic –Give in the U.S under certain conditions Consult Red Book Ribavirin –Not FDA approved, but may help those severely affected and immunocompromised

19. Measles Infection Control Vaccine given within 72 hrs of exposure my provide protection in susceptible individuals Immune globulin given within 6 days of exposure may prevent or modify measles

20. ImmuneWise Advocacy

21. ImmuneWise 5 th Annual Advocacy Project SOMSRFT partnered with Section for Seniors Members Goal: Educate providers and parents Goal: Improve immunization rates Goal: Foster advocacy interest among SOMSRFT members

22. Why?

23. Who Else? Within the AAP, many are concerned Paul Offit, M.D.

24. What about You? Many levels of advocacy –Individual level –Residency program / Clinic level –State level –Federal level

25. Individual Level

26. Individual Advocacy Talk to the Press –Write a letter to the editor –Make yourself available to the media Contact your state legislators –Write a letter or an email –Provide them with information Discuss the issue with parents –Provide parents with info on Myths vs. Facts –Answer questions about vaccine components, side effects, and alternate schedules

27. Myths vs. Facts

28. Program / Clinic Level

29. Program-Wide Advocacy Implement a quality improvement project focused on improving immunization rates Implement an immunization education curriculum

30. Quality Improvement ACGME Program Requirement on Practice Based Learning and Improvement states, “systematically analyze practice using quality improvement methods, and implement changes with the goal of practice improvement- Residents are expected to participate in a quality improvement project.”

31. QI Project Immunization Rates QI projects focused on improving immunization rates can target –Particular vaccine (eg, influenza) –Target population (eg, 2-24 month olds) –Entire population served An example of how to do QI for immunization rates comes from TIDE – Teaching Immunization Delivery and Evaluation

32. Designing QI – Step 1 Assess Immunization Rates (“Plan”) Assessment methods: –Chart method –Active method –Consecutive method Record the assessment data collected There is a sample to download

33. Designing QI – Step 2 Implement Change (“Do”) –Describe and analyze key office routines related to immunizations using an office immunization practices questionnaire There is a sample to download –Based on findings… Select an intervention likely to improve immunization rates Focus on the “vital few” interventions rather than the “useful many”

34. Office Immunization Practices Questionnaire

35. Designing QI – Step 3 Assess the Effects of Change (“Study”) –Assess the immunization rates again (after a set period of time) –Continue to improve your effort after noting barriers / set-backs –Celebrate successes

36. Community Level

37. Community Advocacy Find community supporters and leaders Speak to parent groups Post ImmuneWise posters in key locations Utilize national PSAs at the local level

38. PSA Every Child By Two

39. State Level

40. State Advocacy Each state has their own reimbursement issues

41. State Advocacy Statewide campaigns are an opportunity to partner with AAP Chapters The activities available/needed vary by state, so for more information turn to: –ImmuneWise CD-ROM –AAP Committee on State Government Affairs

42. National / Federal Level

43. national Advocacy National media campaigns underway –Every Child by Two –The Vaccinate Your Baby Web site: www.vaccinateyourbaby.org

44. Federal Advocacy Other opportunities for involvement: –Attend AAP Advocacy Institute March 10-12, 2010 in Chicago –Familiarize yourself with AAP position papers –Become a Key Contact for the AAP Federal Affairs Advocacy Network (FAAN)

45. You Can Make a Difference! Find out the special needs of your clinic or community Develop a project YOU have a passion for Return the Project Outcome Report for ImmuneWise. This will help us improve future advocacy projects! Let us know what you have accomplished. We want to recognize you in district newsletters and !

46. Brought to You By: SOMSRFT Executive Committee Advocacy Subcommittee – Co-Chairs Drs. Katie Snyder and Jennifer Williams – Members Drs. Shawn Batlivala, Clara Filice, Jenni Linebarger, Christina Robinson, Sara Slovin, Josh Smith, Amy Starmer, David Tayloe –Other Contributors/Supporters Lucy Crain, MD, FAAP, Buz Harlor, MD, FAAP, Michael Warren, MD, FAAP, Julie Raymond, Ian Van Dinther