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Am Fam Physician. 2000;61(4):1200-1206

Vaccination of Native American Children

The Committee on Native American Child Health and the Committee on Infectious Diseases of the American Academy of Pediatrics (AAP) have issued a policy statement on the immunization of Native American children. The AAP policy statement appears in the September 1999 issue of Pediatrics.

Native American children are at greater risk for hepatitis A, hepatitis B and diseases caused by Haemophilus influenzae and Streptococcus pneumoniae, as a result of genetics and environment. Because of the prevalence of these illnesses among this population, the AAP committee feels that all physicians must be aware of the different cultural and genetic needs of the patients they treat.

The AAP committee suggests the incorporation of the following recommendations to maximize the efficacy of vaccines currently available for Native American children:

  • Polyribosylribitol phosphate polysaccharide conjugated to a meningococcal outer membrane protein (PRP-OMP) Haemophilus influenzae type B (Hib) conjugate vaccine is the preferred initial immunizing dose for prevention of Haemophilus infections. For subsequent doses, PRP-OMP or any other conjugate Hib vaccine may be used.

  • Hepatitis A vaccine should be administered routinely to all American Indian and Alaska Native children at the earliest recommended age (currently two years). Hepatitis A vaccine should be administered to children between two and 18 years of age who are frequently exposed to persons living in areas with endemic or epidemic hepatitis A.

  • All infants and children should be immunized with hepatitis B vaccine. The age for initiating vaccination depends on the mother's hepatitis B surface antigen status, the local epidemiology of hepatitis B infections and the availability of thimerosal-free vaccines.

  • A single dose of pneumococcal 23-valent polysaccharide vaccine should be considered for Native American children at two years of age who live in areas where an increased risk of invasive pneumococcal disease has been demonstrated after two years of age.

  • To reduce the number of injections, combined PRP-OMP conjugate vaccine/hepatitis B vaccine may be used at visits scheduled for either single vaccine for infants at least six weeks of age.

AHRQ Series of Charts Related to Hospital Care

The Agency for Healthcare Research and Quality (AHRQ), formerly called the Agency for Health Care Policy and Research, has recently released a new series of AHRQ charts related to hospital care. The charts—“Top Five Reasons for Hospital Admission,” “Top Five Most Expensive Hospital Diagnoses” and “Top Five Most Expensive Hospital Procedures”—include information on the five most expensive conditions or principal diagnoses to treat in hospitalized patients. These conditions are spinal cord injury, infant respiratory distress syndrome, low birth weight, leukemia and heart valve disorders.

The AHRQ charts are based on data from two AHRQ reports—“Hospital Inpatient Statistics, 1996” (AHCPR 99-0034) and “Most Common Diagnoses and Procedures in U.S. Community Hospitals, 1996” (AHCPR 99-0046). The AHRQ is offering the charts as part of a new service to make its statistics on the use, cost and quality of the health care of Americans more accessible to the public. The charts can be viewed on the AHRQ Web site (

Prevention of Breast Cancer with Tamoxifen

It was estimated that in 1999, there would be 175,000 new cases of breast cancer in woman and about 43,300 deaths as a result of the disease. Because breast cancer is a significant health problem for women in the United States, the Committee on Gynecologic Practice of the American College of Obstetricians and Gynecologists (ACOG) issued Committee Opinion No. 224 on the role of tamoxifen in preventing breast cancer in high-risk women. The opinion paper appears in the October 1999 issue of Obstetrics and Gynecology.

While gains have been made in the diagnosis and treatment of breast cancer, there has been little success in its prevention. Recently, the Breast Cancer Prevention Trial, which began in 1992, found that the use of tamoxifen in women at high risk of developing breast cancer was associated with a 49 percent reduction in the occurrence of primary disease. A high-risk woman is at least 35 years of age with a five-year predicted risk of breast cancer of at least 1.67 percent based on a combination of variables including family history, current age and personal history of breast abnormalities.

Tamoxifen arrests the growth of breast cancer tumor cells. For 25 years, tamoxifen has been used to treat women with advanced breast cancer. The usefulness of tamoxifen in the possible prevention of breast cancer was suggested by several studies.

Tamoxifen has several side effects, including increased risk of endometrial cancer, pulmonary embolism, deep venous thrombosis and cataracts. Also, little is known about long-term effects of treatment with tamoxifen. According to the ACOG committee, the decision to use tamoxifen should be made on an individual basis after considering patients' medical histories, risk assessments and preferences, and informing patients of the risks and possible side effects of the drug.

NCI Report on the Health Effects of Secondhand Smoke

The National Cancer Institute (NCI) recently released the most comprehensive report to date on the health risks of secondhand smoke, linking secondhand smoke not only with lung cancer but also with heart disease, sudden infant death syndrome, nasal sinus cancer and many other diseases in adults and children.

The 430-page report, “Health Effects of Exposure to Environmental Tobacco Smoke: The Report of the California Environmental Protection Agency,” “. . . confirms what most Americans already know—cigarettes not only pose grave health risks to the smoker, they also threaten the health of anyone who is even near a lighted cigarette, especially children,” said Carol Browner, administrator of the U.S. Environmental Protection Agency.

The report, which was compiled by the California Environmental Protection Agency, estimates that each year in the United States, there are between 35,000 and 62,000 deaths from coronary heart disease related to secondhand smoke. The report includes 18 epidemiologic studies that link secondhand smoke to coronary heart disease.

U.S. Surgeon General David Satcher, M.D., Ph.D., added that the public health burden caused by secondhand smoke “more than justifies public policies creating smokefree workplaces and public areas.”

Copies of the report can be obtained by calling the NCI Cancer Information Service at 800-4-CANCER or by accessing the NCI Web site ( The report is also being made available to each state health department by the Centers for Disease Control and Prevention.

HIV Transmission in Children

The Committee on Pediatric AIDS and the Committee on Infectious Diseases of the American Academy of Pediatrics (AAP) have issued a new policy statement concerning the transmission of human immunodeficiency virus (HIV) in schools, child care facilities, medical settings, the home and the community. The policy statement appears in the August 1999 issue of Pediatrics.

The AAP policy statement includes the following recommendations:

  • Persons in homes, schools and child care settings who may have contact with blood or body fluids should be educated about Standard Precautions to prevent transmission of HIV.

  • In any setting, blood or body fluids from children should be handled using Standard Precautions.

  • In health care facilities, hands should be washed immediately before and after patient contact, and after glove removal.

  • Standard Precautions for routine use in hospitals are as follows: (1) the routine use of gloves, gowns and masks is recommended; (2) hands and other skin surfaces should be washed immediately and thoroughly after contact with blood or body fluids; (3) hands should be washed immediately after gloves are removed; (4) environmental surfaces contaminated with blood or body fluids should be cleaned and disinfected; (5) gloves should be worn during cleaning and disinfecting procedures.

  • Children with HIV infection should be managed the same as healthy children.

  • In the delivery room, newborn infants should be handled with gloves until blood and amniotic fluid have been removed from the infants' skin.

  • Hospitalized children with HIV infection should not have separate waiting rooms or hospital rooms unless they have other conditions requiring such isolation.

  • Needles should never be recapped. Syringes, needles and other sharp instruments should be disposed of in puncture-resistant containers.

  • Instruments contaminated with blood or body fluids should be cleaned and sterilized or appropriately discarded.

  • Routine screening of health care workers for HIV is not recommended.

  • HIV-infected children should be admitted without restriction to child-care facilities and schools and allowed to participate in all activities to the extent that their health permits.

  • Informing child care and school personnel of a child's HIV status is not required.

  • These recommendations should be applied universally in the United States.

Role of Exercise in CHD Prevention

Coronary heart disease (CHD) is the leading cause of death in men and women, although more women than men die of CHD each year, reports the November 1999 Current Comment from the American College of Sports Medicine. Many people mistakenly believe that breast cancer and osteoporosis are the greatest health risks for women, even though the lifetime risk of death from CHD among postmenopausal women is approximately 31 percent, compared with 2.8 percent for hip fracture and breast cancer alike.

According to the Current Comment, preventive strategies can significantly lower the risk of CHD in men and women. Patients should be encouraged to increase physical activity, because it is the lifestyle change most likely to be effective in the prevention of CHD. Physical activity has been shown to favorably alter risk factors such as dyslipidemia, obesity, type 2 diabetes mellitus (formerly known as non–insulin-dependent diabetes mellitus) and high blood pressure.

For more information on women's heart health and a physically active lifestyle, write to the American College of Sports Medicine, P.O. Box 1440, Indianapolis, IN 46206-1440.

Prevalence of Inhalant Abuse in Children

Most children and adolescents say they are aware of people who breathe in fumes of household products such as glue, paint and cleaners, and nearly 25 percent say their friends “huff,” according to a nationwide survey on inhalant abuse. The survey was sponsored by the American Academy of Pediatrics (AAP).

The survey found that 62 percent of the 10- to 17-year-olds surveyed know what huffing is. Children are an average of 12 years of age when they first know about classmates who abuse inhalants. Only 67 percent of children 10 to 11 years of age have learned about inhalants in the classroom, and only 48 percent have talked with their parents about inhalant abuse, but this age group is the most likely to have been personally exposed to inhalants.

Children abuse inhalants for many reasons, according to the AAP. They are cheap, easy to get and easy to hide. Inhalants are legal substances, and many children enjoy the “high” and the social appeal of “huffing” with friends.

Some of the signs and symptoms of inhalant abuse include the following: breath and clothing that smell like chemicals; spots or sores around the child's mouth; paint or stains on the child's body or clothing; drunk, dazed or glassy-eyed look; nausea or loss of appetite; and anxiety, excitability or irritability.

“Abusing inhalants can cause severe permanent damage, especially to the brain,” said AAP President Joel J. Alpert, M.D. “The scariest thing about inhalants is that your child could die from using them only once.”

The AAP says that the most effective way to prevent inhalant abuse is by educating parents, teachers and children about the signs, symptoms and dangers. Parents can influence children's decision not to abuse inhalants by not using drugs themselves, and by providing guidance and clear rules about not abusing substances.

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