Letters to the Editor - November 1, 1999 - American Academy of Family Physicians

Letters to the Editor

Cost of Inactivated vs. Oral Poliovirus Vaccine

TO THE EDITOR: The article on "Poliovirus Vaccine Options,"¹ written by Zimmerman and Spann, provides cogent reasons for the regimen of combined inactivated poliovirus vaccine (IPV) and oral poliovirus vaccine (OPV). What is not addressed in this or any other article of its type is the issue of vaccine cost and reimbursement.

The authors state that "the costs for IPV and OPV schedules are similar in the private sector."¹ This is not true in the sector in which I practice (Reading, Pa.). The cost of OPV for my practice is $10, compared with a cost of $35 for IPV. Obviously, reimbursement does not match our outlay. Furthermore, most of the pharmaceutical companies that manufacture vaccines provide major price breaks for bulk purchases or require a $500 minimum purchase. As a solo practitioner who sees a small but steady number of newborns, I am being placed in the position of subsidizing vaccine costs from my diminishing practice revenues.

Even the Commonwealth of Pennsylvania, which mandates coverage of vaccine costs by all insurers, is not helpful because these costs are reflective of bulk purchases and not small lots. Finally, managed health care organizations are often sluggish when it comes to deciding how and when to reimburse for new or altered vaccine regimens regardless of whether reimbursement is realized as fee-for-service or included in capitation. In short, because quality pediatric care mandates correct administration of vaccines, and because the small practice may find it financially difficult to purchase these vaccines in the face of uncertain or inadequate reimbursement, we may be forced out of pediatric practice.

JONATHAN R. DREAZEN, M.D.
3701 Perkiomen Ave.
Reading, PA 19606

REFERENCE

Zimmerman RK, Spann SJ. Poliovirus vaccine options. Am Fam Physician 1999;59:113-8.

IN REPLY: I practice part-time in an inner city health center of modest size in Pittsburgh, which serves the poor and homeless. Thus, I am personally aware of the problems of price.

The question about an equivalent price was initiated by a reviewer for American Family Physician who read an earlier draft of my article where I listed cost as a disadvantage of inactivated poliovirus vaccine (IPV). The reviewer checked his records and found that the costs were quite similar. I then checked my practice records and found that the costs were similar (IPV is more expensive for the government to buy and the book price is higher). After receiving your e-mail, I asked my office staff to once again check prices. On our last order, we paid $146.30 for 10 doses of IPV ($14.63 per dose) and $144.24 for 10 doses of oral poliovirus vaccine (OPV) ($14.42 per dose). IPV can be ordered from the manufacturer, Pasteur Merieux Connaught (PMC), at 800-822-2463. So, for my inner-city Pittsburgh practice, the prices are equivalent. I ask you to call PMC, ask for the price and let me know.

A patient of my father's practice was a polio victim and a family friend. From watching his decline and struggles, I know of the suffering caused by polio. In national meetings, I have also seen those who have or have a relative with vaccine-associated paralytic polio (VAPP). Persons with VAPP suffer. I believe that an ethical issue is whether or not we continue to use an all-OPV schedule, knowing that a few of the vaccine recipients will be paralyzed from OPV. I cannot do this any longer, unless the child is traveling overseas soon or in some other special circumstance. IPV is clearly safer. Even if a small difference in price occurs, can we ethically continue the all-OPV schedule routinely when indigenous, wild polio has been eradicated in the United States for years?

RICHARD K. ZIMMERMAN, M.D., M.P.H.
Department of Family Medicine and Clinical Epidemiology
University of Pittsburgh School of Medicine
M-200 Alan Magee Scaife Hall of the Health Professions
Pittsburgh, PA 15261

Antibiotic Therapy for Viral Infections in Children

TABLE
Web Sites for Current Surveillance Information on Influenza that Provide State and Regional-Specific Information

Centers for Disease Control and Prevention
http://www.cdc.gov/ncidod/diseases/flu/fluvirus.htm
(Provides the gold standard for influenza surveillance with data resulting from four surveillance mechanisms.)
Johns Hopkins Health Information
http://www.intelihealth.com
(Features an interactive flu map on a seasonal basis.)
ZymeTx, Inc.
http://www.fluwatch.com
(Features results of rapid influenza antigen tests [commercial site sponsored by the makers of ZstatFlu].)

TO THE EDITOR: In a recent "Curbside Consultation" entitled, "When a Parent Insists on Antibiotics for a Virus,"¹ Dr. Marcy offers readers a wonderful pearl. The prescription of antibiotics for viral infections in children is all too common in ambulatory care, and the scenario often relates to the quality of physician-parent-patient interaction.² The succinct, five-step approach to patient care is well-described and works in everyday practice: (1) affirmation and reassurance, (2) education on etiology, (3) anticipatory guidance, (4) empowerment and (5) follow-up. In our residency clinic, we have been highly successful in reducing inappropriate antibiotic prescriptions in much the same way.

We have enhanced the process by making use of an existing respiratory virus surveillance system in Wisconsin.³ Our faculty and resident physicians are able to provide patients (and their parents) with the name of the most likely etiologic agent (e.g., rhinovirus, influenza, respiratory syncytial virus or parainfluenza virus) based on ongoing surveillance information. Knowing the likely name of the apparent viral infection appears to decrease parents' desire for antibiotics. This approach has resulted in an estimated 3.3 percent rate of antibiotic prescribing for upper respiratory infections (URIs) by all clinicians in our clinic in 1998. Furthermore, URI is by far our most common acute respiratory infection diagnosis.

Recent microbiologic studies^4,5 support Dr. Marcy's approach of education and watchful waiting in most acute respiratory infections. Moreover, studies of patients and parents have demonstrated the important role of information and education.^2,6 Although respiratory virus surveillance is not readily available in most locations, several Web sites offer influenza surveillance (see the accompanying table).

Because of the ever-increasing problems associated with the emergence of antibiotic-resistant bacteria, reasonable steps to promote more judicious use of antibiotics are most welcome. Family physicians should be encouraged to follow Dr. Marcy's approach through this time-efficient enhancement of physician-patient interactions.

JONATHAN L. TEMTE, M.D., PH.D.
Department of Family Medicine
University of Wisconsin Medical School
777 South Mills St.
Madison, WI 53715

Dr. Temte serves on the Influenza Advisory Board of Glaxco Wellcome.

REFERENCES

Marcy SM. When a parent insists on antibiotics for a virus. Am Fam Physician 1999;59:687-8.

Hamm RM, Hicks RJ, Bemben DA. Antibiotics and respiratory infection. J Fam Pract 1996;43:56-62.

Temte JL, Shult PA, Kirk CJ, Amspaugh J. Effects of viral respiratory disease education and surveillance on antibiotic prescribing. Fam Med 1999;31:101-6.

Makela MJ, Puhakka T, Ruuskanen O, Leinonen M, Saikku P, Kimpimaki M, et al. Viruses and bacteria in the etiology of the common cold. J Clin Microbiol 1998;36:539-42.

Heikkinen T, Thint M, Chonmaitree T. Prevalence of various respiratory viruses in the middle ear during acute otitis media. N Engl J Med 1999;340:260-4.

Barden LS, Dowell SF, Schwartz B, Lackey C. Current attitudes regarding use of antimicrobial agents. Clin Pediatr 1998;37:665-71.

IN REPLY: Dr. Temte offers an additional method of reassuring parents and patients that antibiotics may not be required for an upper respiratory infection (URI). Although physicians in Wisconsin are essentially telling their patients that "it's just a virus," knowing the most likely agent and identifying it by name projects a comforting aura of diagnostic certainty. The recognition that this is based on a statewide surveillance provides the added consolation of shared experience: "There's a lot of that going around." The astoundingly low 3.3 percent URI antibiotic prescription rate achieved by the Wisconsin group apparently confirms the results of Barden's study¹: parents and patients will accept not receiving a prescription for antibiotics if physicians take the time to explain why they're not being given one.

Although access to a respiratory virus surveillance system will vary from state to state, validating the effectiveness of Dr. Temte's program with a controlled study and an analysis of its cost-benefit could provide a stimulus for making such information more widely and readily available. His data suggest that an informed physician, particularly one able to educate the patients and parents under his or her care, represents our best hope for promoting rational use of antimicrobial therapy.^2,3

S. MICHAEL MARCY, M.D.
Staff Pediatrician
Kaiser Foundation Hospital
Panorama City, CA 91402
Clinical Professor of Pediatrics
University of Southern California School of Medicine and University of California, Los Angeles, School of Medicine
Los Angeles, CA 90033

REFERENCES

Barden LS, Dowell SF, Schwartz B, Lackey C. Current attitudes regarding use of antimicrobial agents. Clin Pediatr 1998;37:665-71.

Temte JL, Shult PA, Kirk CJ, Amspaugh J. Effects of viral respiratory disease education and surveillance on antibiotic prescribing. Fam Med 1999;31:101-6.

Bauchner H, Pelton ST, Klein JO. Parents, physicians, and antibiotic use. Pediatrics 1999;103:395-401.

Preventing Unnecessary Hypospadias Repair

TO THE EDITOR: We would like to point out that in the examination of a neonate with apparent hypospadias, physicians should not overlook observing the neonate actually voiding.

Micturition from the orifice in the meatus of the glans demonstrates that this is not a hypospadias. The aparent lower "orifice" is only a cosmetic defect.

We encountered a six-month-old infant who appeared to have a hypospadias with the orifice close to the penoscrotal junction (see the accompanying figure). Observation of the infant during micturition revealed that the true orifice was located in the glans. The apparent lower orifice was only a cosmetic defect, and a hypospadias repair was not indicated.

For physicians considering whether hypospadias repair is advisable, we believe there are some reports in the literature that warrant consideration. Mureau and colleagues¹ studied patients who underwent hypospadias repair as infants. The postoperative reports stated satisfactory results. As adults, the patients were queried if they were satisfied with the results of their surgery. The study reports that "there was hardly any agreement between patient and surgeon satisfaction. . . . Patients were less satisfied."

Fichtner and colleagues² studied meatal location in 500 "normal" men. They concluded that "the meatal location varied widely with only 55 percent of all meatus at the tip of the glans and significant hypospadias in patients without complaints about cosmetic or functional aspects. . . . These observations might question the need for meatal advancement in cases of anterior hypospadias without associated penile curvature."

It is apparent from these reports that hypospadias does not always require repair. In addition, appearances may be deceiving and an apparent meatus may be only a dimple.

RABBI JACOB SHECHET, MOHEL
P.O. Box 461911
Los Angeles, CA 90046
BARTON TANENBAUM, M.D., F.A.C.S.
Beverly Hills, CA

REFERENCES

Mureau MA, Slijper FM, Slob AK, Verhulst FC, Nijman RJ. Satisfaction with penile appearance after hypospadias surgery. J Urol 1996;155:703-6.

Fichtner J, Filipas D, Mottrie AM, Voges GE, Hohenfellner R. Analysis of meatal location in 500 men. J Urol 1995;154:833-4.

Correction

Figure 1 in the article "Aseptic Meningitis in the Newborn and Young Infant" (May 15, 1999, page 2767), providing an algorithm on diagnosis and treatment, contained an error in the placement of a decision branch stemming from the point at which a positive latex antigen test or Gram stain is obtained. The corrected algorithm is reprinted in its entirety on page 1936.

*These corrections have been made to the online version of AFP. The links above will take you to the corrected items, which remain part of the online issues in which they were originally published.

Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672; fax:913-906-6080; e-mail: afplet@aafp.org. Please include your complete address, telephone number and fax number. Letters should be double-spaced, fewer than 500 words and limited to one table or figure and six references. Please submit a word count. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter constitutes transfer of copyright to the American Academy of Family Physicians. The editors may edit letters to meet style and space requirements.

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