A Child's Health Is the Public's Health: Progress and Gaps in Addressing Pediatric Needs in Public Health Emergencies.

Children are the most prevalent vulnerable population in US society and have unique needs during the response to and recovery from public health emergencies. The physiological, behavioral, developmental, social, and mental health differences of children require specific attention in preparedness efforts. Despite often being more severely affected in disasters, children's needs are historically underrepresented in preparedness. Since 2001, much progress has been made in addressing this disparity through better pediatric incorporation in preparedness planning from national to local levels. Innovative approaches, policies, and collaborations contribute to these advances. However, many gaps remain in the appropriate and proportional inclusion of children in planning for public health emergencies. Successful models of pediatric planning can be developed, evaluated, and widely disseminated to ensure that further progress can be achieved.

Utilizing a Pediatric Disaster Coalition Model to Increase Pediatric Critical Care Surge Capacity in New York City.

A mass casualty event can result in an overwhelming number of critically injured pediatric victims that exceeds the available capacity of pediatric critical care (PCC) units, both locally and regionally. To address these gaps, the New York City (NYC) Pediatric Disaster Coalition (PDC) was established. The PDC includes experts in emergency preparedness, critical care, surgery, and emergency medicine from 18 of 25 major NYC PCC-capable hospitals. A PCC surge committee created recommendations for making additional PCC beds available with an emphasis on space, staff, stuff (equipment), and systems. The PDC assisted 15 hospitals in creating PCC surge plans by utilizing template plans and site visits. These plans created an additional 153 potential PCC surge beds. Seven hospitals tested their plans through drills. The purpose of this article was to demonstrate the need for planning for disasters involving children and to provide a stepwise, replicable model for establishing a PDC, with one of its primary goals focused on facilitating PCC surge planning. The process we describe for developing a PDC can be replicated to communities of any size, setting, or location. We offer our model as an example for other cities. (Disaster Med Public Health Preparedness. 2017;11:473-478).

Association of RSV-related hospitalization and non-compliance with palivizumab among commercially insured infants: a retrospective claims analysis.

BACKGROUND: Palivizumab has been shown to decrease the incidence of hospitalization due to respiratory syncytial virus (RSV) in infants at risk of severe RSV disease. We examined the association between compliance with palivizumab dosing throughout the RSV season and risk of RSV-related hospitalization in clinical practice. METHODS: Subjects who were born and discharged from the hospital before the RSV season and received ≥1 palivizumab dose during their first RSV season were identified from a large US commercial health insurance database between 01/01/03 and 12/31/09. Subjects were deemed compliant if they received ≥5 palivizumab doses without gaps (>35 days) and their first dose was received by November 30. RSV-related hospitalizations were identified using ICD-9-CM diagnosis codes and examined over 2 observation periods: post-index dose and RSV season. A Cox proportional hazard model was used to evaluate the association between non-compliance and RSV-related hospitalization. RESULTS: Of the 5,003 subjects who received palivizumab, 62% were deemed non-compliant. Non-compliant subjects had significantly higher unadjusted rates of RSV-related hospitalizations compared to compliant subjects during both observation periods (post-index: 6.1 vs. 2.8 per 100 infant seasons, p < 0.001; RSV season: 5.9% vs. 2.3%; p < 0.001). In multivariate analyses, non-compliance was significantly associated with higher risk of RSV-related hospitalization (HR = 2.01; p < 0.001). Of the 225 RSV-related hospitalizations observed during the RSV season, 61 (27%) occurred before the first dose of palivizumab. CONCLUSIONS: Subjects who did not receive monthly dosing of palivizumab throughout the RSV season had significantly higher rates of RSV-related hospitalizations. The RSV-related hospitalizations prior to the first dose of palivizumab suggest some dosing was started too late.

A systematic review of compliance with palivizumab administration for RSV immunoprophylaxis.

BACKGROUND: Respiratory syncytial virus (RSV) is a leading cause of lower respiratory tract infection (LRTI) in infants and young children, accounting for approximately 75,000-125,000 hospitalizations per year. It is estimated that in 2000, RSV infection accounted for 1.7 million office visits, 402,000 emergency room visits, and 236,000 hospital outpatient visits per year for children younger than 5 years of age. Palivizumab, a humanized monoclonal antibody directed against RSV, is the only immunoprophylaxis therapy approved by the FDA for prevention of serious lower respiratory tract disease caused by RSV in infants (up to 2 years of age) who meet 1 or more of the following criteria for high risk: (a) gestational age up to 35 weeks;(b) diagnosis of chronic lung disease (CLD, formerly bronchopulmonary dysplasia [BPD]); or (c) diagnosis of cyanotic or complex congenital heart disease. The RSV season typically occurs between November and March but may vary by region. During the period of our review, depending on local duration of the RSV season, infants usually required 5 monthly (every 28-30 days) intramuscular injections of palivizumab. Infants born in the middle of the season received their palivizumab doses from the time of birth to the end of the season and, therefore, may have required less than 5 doses.It is unclear if compliance with monthly doses is a problem and whether noncompliance increases the risk of RSV hospitalizations in routine clinical practice. OBJECTIVES: To (a) identify and describe compliance rates and the factors that influence parental compliance with immunoprophylaxis regimens, (b)review intervention programs and describe those that have been associated with increased compliance, and (c) summarize the association of compliance with RSV hospitalization rates. METHODS: An electronic literature search was conducted using journal databases, including Ovid, Current Contents, Embase, Medline In-Process & Other Non-Indexed Citations; Ovid Medline, PubMed, and Web of Science;and an abstract database, Medical Intelligence Solution, for citations through April 2008. Specific search terms used were palivizumab with patient compliance, patient adherence, or patient persistence. RESULTS: Twenty-five articles and abstracts met the inclusion criteria. Available studies were mostly retrospective or observational prospective.Compliance, defined in various ways across the studies, varied between 25% and 100%, and 12 studies identified some of the factors related to noncompliance. Compliance generally was lower among Medicaid patients,African American patients, and other minorities. Ten studies (3 manuscripts and 7 abstracts) investigated the association of administration of prophylaxis through monthly home visits by a health professional with parental compliance with therapy. Most of the home-based programs were associated with higher compliance rates compared with clinic or office programs.Rates as high as 94% and 64% were achieved when Medicaid infants and infants of minority descent, respectively, received their doses through a home health program. When these infants received their doses at a clinic or office, depending on the definition of compliance, rates were 61%-100% for Medicaid infants and 44% for infants of minority descent. Reminder telephone calls to parents or caregivers, comprehensive multidisciplinary programs that included extensive counseling of parents, calendars with sticker reminders, and education in the language native to parents also were associated with increased compliance, although statistical significance was reported in only 1 study. Several studies recommended educating parents on the benefits of RSV prophylaxis, alleviating transportation and language difficulties, recognizing cultural differences and biases, and clarifying misperception of RSV illness severity. Home health programs had lower rates of RSV hospitalizations than office-based programs in 3 analyses conducted in 2 studies. In 4 other abstracts, the rates of RSV hospitalization for home health programs and office-based administration did not significantly differ. In a large, 4-season, prospective outcome study, compliant infants had lower RSV hospitalization rates than those who were not compliant under one definition of compliance (doses within 35-day intervals). RSV hospitalization rates were not significantly different using another definition of compliance (receipt of anticipated doses, expected vs. observed rates).In a large survey of 10,390 infants identified from pharmacy dispensing records, RSV hospitalization rates were 1.4% in the compliant group versus 3.1% in the noncompliant group (OR = 2.2, 95% CI = 1.4-3.5, P < 0.001).Adjustment for confounding was not reported in these studies. CONCLUSION: Medicaid and minority infants were less likely to receive scheduled palivizumab doses. Home-based programs for the administration of palivizumab have been investigated more than other interventions and are associated with improved compliance compared with office-based administration. Compliance with dosing, in general, was associated with lower RSV hospitalization rates. However, these strategies should be further investigated using well-designed studies.

In the trenches: a pediatrician's perspective on prevention and treatment strategies for RSV disease.

Pharmacologic options in the treatment of RSV infection have no or minimal effectiveness. Therefore, for infants at high risk of RSV infection, proper hand hygiene, limiting exposure to infection, and immunoprophylaxis with palivizumab is paramount. The first injection of palivizumab must be given prior to the start of the local RSV season and subsequent injections should be administered every 30 days to provide protective levels until the end of the RSV season. Pediatricians should anticipate the start of the RSV season and attend to reimbursement issues and obtain all necessary approvals well in advance of the time when the first injections will be given. Compliance is the key to providing protection for high-risk infants. Compliance has a positive association with decreasing RSV hospitalization rates; however, it is difficult for pediatricians to achieve optimal compliance on their own. A collaborative effort involving the hospital and NICU, pediatrician, parent, home care provider, and insurer is necessary to achieve optimal compliance.

Improved outcomes with home-based administration of palivizumab: results from the 2000-2004 Palivizumab Outcomes Registry.

BACKGROUND: Palivizumab Outcomes Registry data collected during 4 years were examined to assess compliance and respiratory syncytial virus (RSV) hospitalization rates in high-risk children receiving palivizumab prophylaxis at home compared with an outpatient setting. METHODS: Prospective observational registry enrolling high-risk infants who received > or = 1 dose of palivizumab throughout the 2000-2001 to 2003-2004 RSV seasons at participating U.S. pediatric sites. RESULTS: Registry data were analyzed for compliance and RSV hospitalization outcomes in 19,548 infants receiving doses at home versus an outpatient setting. Compliance with the injection regimen was determined by comparing the number of palivizumab injections received versus the projected number of anticipated doses and by comparing infants receiving all injections within a 35-day interval. Compliance was significantly greater for infants who received palivizumab at home (n = 1226) as compared with those who received palivizumab in a clinic or office (n = 17,641), whether measured by the number of doses received (88% versus 81%, P < 0.0001) or by the timing of doses (73% versus 66%, P < 0.0001). Infants who received palivizumab at home also had fewer RSV-associated hospitalizations compared with those who received palivizumab in a clinic or office [0.4% (5/1226) versus 1.2% (207/17,641), P = 0.0139]. CONCLUSIONS: Home administration of palivizumab was associated with a significantly higher rate of compliance and lower hospitalization rate for RSV illness in high-risk infants.