Pediatrics

Over half of pediatric rheumatology fellowship positions went unfilled in 2024, according to the National Resident Matching Program (NRMP). Comparatively, nearly all adult rheumatology positions were filled.

Across all 39 subspecialties in internal medicine and pediatrics, there was an 86% fill rate. In pediatric subspecialties, the fill rate was 78%. There were more than 10,200 applicants in this year’s medicine and pediatric specialties match — a 9% increase from 2023 — and 81% matched to a position. 

The NRMP reported that adult rheumatology filled 129 (97.7%) of 132 programs, with 284 (99%) out of 287 positions filled. In 2024, there were five new programs and 11 more fellowship positions available compared with the previous year. 

In pediatric rheumatology, 16 (44%) of 36 programs were filled, with 27 (49%) of 55 positions filled. This is a notable decrease from 2023, where pediatric rheumatology filled 21 of 38 programs (55%) and 32 (62%) of 52 positions.

This year, 27 of 30 applicants preferring pediatric rheumatology matched to a program, while in 2023 all 32 applicants that preferred pediatric rheumatology matched.

“It’s a little disappointing that our overall number of applicants have not gone up,” Jay Mehta, MD, the program director of the Children’s Hospital of Philadelphia’s pediatric rheumatology fellowship said in an interview with Medscape Medical News. “It’s an especially exciting time in pediatric rheumatology, with really fantastic breakthroughs in terms of treatments and diagnostics. Unfortunately, that excitement hasn’t necessarily translated into more interest in our field.”

Mehta noted that the number of applicants to pediatric rheumatology fellowships have remained relatively consistent. Since 2019, the number of applicants has ranged from 28 to 33. 

“Given the low number of overall positions/programs it is hard to read too much into year-to-year differences,” added Kristen Hayward, MD, a pediatric rheumatologist at Seattle Children’s in Washington. “While this total number of applicants per year is steady, this number is insufficient to build an adequate workforce for our current needs, much less for the future.” 

This year, matched applicants to pediatric rheumatology included 13 MD graduates, eight DO graduates, five foreign applicants, and one US citizen international medical graduate. 

In adult rheumatology, matched applicants included 108 MD graduates, 97 foreign applicants, 41 DO graduates, and 38 US citizen international medical graduates. A total of 365 applicants preferred the specialty, and 76% matched to rheumatology. Seven applicants matched to another specialty, and the remaining 79 did not match to any program.

Rheumatology was one of several specialties offering at least 150 positions with a fill rate of over 98%. The other specialties included allergy and immunology, cardiovascular disease, clinical cardiac electrophysiology, endocrinology, gastroenterology, and hematology and oncology. 

While some pediatric subspecialties like critical care medicine and cardiology had fill rates over 90%, many “cognitive subspecialties” beyond pediatric rheumatology also struggled to fill spots, Hayward noted. Only 37% of pediatric nephrology positions and 48% of pediatric infectious disease positions were filled this year, in addition to a decline in filled pediatric-residency positions overall, she added.

Mehta had no relevant disclosures. Hayward previously owned stock/stock options for AbbVie/Abbott, Cigna/Express Scripts, Merck, and Teva and has received an educational grant from Pfizer.

A version of this article first appeared on Medscape.com.

Over half of pediatric rheumatology fellowship positions went unfilled in 2024, according to the National Resident Matching Program (NRMP). Comparatively, nearly all adult rheumatology positions were filled.

Across all 39 subspecialties in internal medicine and pediatrics, there was an 86% fill rate. In pediatric subspecialties, the fill rate was 78%. There were more than 10,200 applicants in this year’s medicine and pediatric specialties match — a 9% increase from 2023 — and 81% matched to a position. 

The NRMP reported that adult rheumatology filled 129 (97.7%) of 132 programs, with 284 (99%) out of 287 positions filled. In 2024, there were five new programs and 11 more fellowship positions available compared with the previous year. 

In pediatric rheumatology, 16 (44%) of 36 programs were filled, with 27 (49%) of 55 positions filled. This is a notable decrease from 2023, where pediatric rheumatology filled 21 of 38 programs (55%) and 32 (62%) of 52 positions.

This year, 27 of 30 applicants preferring pediatric rheumatology matched to a program, while in 2023 all 32 applicants that preferred pediatric rheumatology matched.

“It’s a little disappointing that our overall number of applicants have not gone up,” Jay Mehta, MD, the program director of the Children’s Hospital of Philadelphia’s pediatric rheumatology fellowship said in an interview with Medscape Medical News. “It’s an especially exciting time in pediatric rheumatology, with really fantastic breakthroughs in terms of treatments and diagnostics. Unfortunately, that excitement hasn’t necessarily translated into more interest in our field.”

Mehta noted that the number of applicants to pediatric rheumatology fellowships have remained relatively consistent. Since 2019, the number of applicants has ranged from 28 to 33. 

“Given the low number of overall positions/programs it is hard to read too much into year-to-year differences,” added Kristen Hayward, MD, a pediatric rheumatologist at Seattle Children’s in Washington. “While this total number of applicants per year is steady, this number is insufficient to build an adequate workforce for our current needs, much less for the future.” 

This year, matched applicants to pediatric rheumatology included 13 MD graduates, eight DO graduates, five foreign applicants, and one US citizen international medical graduate. 

In adult rheumatology, matched applicants included 108 MD graduates, 97 foreign applicants, 41 DO graduates, and 38 US citizen international medical graduates. A total of 365 applicants preferred the specialty, and 76% matched to rheumatology. Seven applicants matched to another specialty, and the remaining 79 did not match to any program.

Rheumatology was one of several specialties offering at least 150 positions with a fill rate of over 98%. The other specialties included allergy and immunology, cardiovascular disease, clinical cardiac electrophysiology, endocrinology, gastroenterology, and hematology and oncology. 

While some pediatric subspecialties like critical care medicine and cardiology had fill rates over 90%, many “cognitive subspecialties” beyond pediatric rheumatology also struggled to fill spots, Hayward noted. Only 37% of pediatric nephrology positions and 48% of pediatric infectious disease positions were filled this year, in addition to a decline in filled pediatric-residency positions overall, she added.

Mehta had no relevant disclosures. Hayward previously owned stock/stock options for AbbVie/Abbott, Cigna/Express Scripts, Merck, and Teva and has received an educational grant from Pfizer.

A version of this article first appeared on Medscape.com.

Over half of pediatric rheumatology fellowship positions went unfilled in 2024, according to the National Resident Matching Program (NRMP). Comparatively, nearly all adult rheumatology positions were filled.

Across all 39 subspecialties in internal medicine and pediatrics, there was an 86% fill rate. In pediatric subspecialties, the fill rate was 78%. There were more than 10,200 applicants in this year’s medicine and pediatric specialties match — a 9% increase from 2023 — and 81% matched to a position. 

The NRMP reported that adult rheumatology filled 129 (97.7%) of 132 programs, with 284 (99%) out of 287 positions filled. In 2024, there were five new programs and 11 more fellowship positions available compared with the previous year. 

In pediatric rheumatology, 16 (44%) of 36 programs were filled, with 27 (49%) of 55 positions filled. This is a notable decrease from 2023, where pediatric rheumatology filled 21 of 38 programs (55%) and 32 (62%) of 52 positions.

This year, 27 of 30 applicants preferring pediatric rheumatology matched to a program, while in 2023 all 32 applicants that preferred pediatric rheumatology matched.

“It’s a little disappointing that our overall number of applicants have not gone up,” Jay Mehta, MD, the program director of the Children’s Hospital of Philadelphia’s pediatric rheumatology fellowship said in an interview with Medscape Medical News. “It’s an especially exciting time in pediatric rheumatology, with really fantastic breakthroughs in terms of treatments and diagnostics. Unfortunately, that excitement hasn’t necessarily translated into more interest in our field.”

Mehta noted that the number of applicants to pediatric rheumatology fellowships have remained relatively consistent. Since 2019, the number of applicants has ranged from 28 to 33. 

“Given the low number of overall positions/programs it is hard to read too much into year-to-year differences,” added Kristen Hayward, MD, a pediatric rheumatologist at Seattle Children’s in Washington. “While this total number of applicants per year is steady, this number is insufficient to build an adequate workforce for our current needs, much less for the future.” 

This year, matched applicants to pediatric rheumatology included 13 MD graduates, eight DO graduates, five foreign applicants, and one US citizen international medical graduate. 

In adult rheumatology, matched applicants included 108 MD graduates, 97 foreign applicants, 41 DO graduates, and 38 US citizen international medical graduates. A total of 365 applicants preferred the specialty, and 76% matched to rheumatology. Seven applicants matched to another specialty, and the remaining 79 did not match to any program.

Rheumatology was one of several specialties offering at least 150 positions with a fill rate of over 98%. The other specialties included allergy and immunology, cardiovascular disease, clinical cardiac electrophysiology, endocrinology, gastroenterology, and hematology and oncology. 

While some pediatric subspecialties like critical care medicine and cardiology had fill rates over 90%, many “cognitive subspecialties” beyond pediatric rheumatology also struggled to fill spots, Hayward noted. Only 37% of pediatric nephrology positions and 48% of pediatric infectious disease positions were filled this year, in addition to a decline in filled pediatric-residency positions overall, she added.

Mehta had no relevant disclosures. Hayward previously owned stock/stock options for AbbVie/Abbott, Cigna/Express Scripts, Merck, and Teva and has received an educational grant from Pfizer.

A version of this article first appeared on Medscape.com.

WASHINGTON — A quality improvement project aimed at reducing racial disparities in juvenile idiopathic arthritis (JIA) led to a modest reduction in the overall clinical Juvenile Arthritis Disease Activity Score (cJADAS) and a 17% reduction in the disparity gap between Black and White patients, according to a study presented at the annual meeting of the American College of Rheumatology.

“Our work has led to initial progress in all groups, but we did not fully close the gap in outcomes,” Dori Abel, MD, MSHP, an attending rheumatologist at Children’s Hospital of Philadelphia in Pennsylvania, told attendees. But the project still revealed that it’s feasible to improve outcomes and reduce disparities with a “multipronged, equity-driven approach,” she said. “Stratifying data by demographic variables can reveal important differences in health care delivery and outcomes, catalyzing improvement efforts.”

Giya Harry, MD, MPH, MSc, an associate professor of pediatric rheumatology at Wake Forest University School of Medicine in Winston-Salem, North Carolina, was not involved in the study but praised both the effort and the progress made.

“The results are promising and suggest that with additional interventions targeting other key drivers, the team may be successful in completely eliminating the disparity in outcomes,” Harry said in an interview. “I applaud the hard work of Dr Abel and the other members of the team for doing the important work of characterizing the very complex issue of disparities in JIA outcomes across different race groups.” 

It will now be important to build upon what the physicians learned during this process, said Harry, also the chair of the Diversity, Equity, Inclusion, and Accessibility committee of the Childhood Arthritis and Rheumatology Research Alliance.

“Patience is needed as they cycle through interventions with an emphasis on other key drivers” of disparities, Harry said.

 

Targeting Factors That Clinicians Can Potentially Influence

In her presentation, Abel discussed the various barriers that interfere with patients’ ability to move up the “JIA escalator” of getting referred and diagnosed, starting treatment and getting control of the disease, and monitoring and managing the disease and flares. These barriers include difficulties with access, trust, finances, insurance, caregivers’ missed work, medication burden, side effects, system barriers, and exhaustion and depression among caregivers and patients.

These barriers then contribute to disparities in JIA outcomes. In the STOP-JIA study, for example, Black children had greater polyarthritis disease activity in the first year and greater odds of radiographic damage, Abel noted. At her own institution, despite a mean cJADAS of 2.9 for the whole population of patients with JIA, the average was 5.0 for non-Hispanic Black patients, compared with 2.6 for non-Hispanic White patients.

The team therefore developed and implemented a quality improvement initiative aimed at improving the overall mean cJADAS and narrowing the gap between Black and White patients. The goal was to reduce the mean cJADAS to 2.7 by July 2024 and simultaneously reduce the cJADAS in Black patients by 1.2 units, or 50% of the baseline disparity gap, without increasing the existing gap.

The team first explored the many overlapping and interacting drivers of disparities within the realms of community characteristics, JIA treatment course, patient/family characteristics, organizational infrastructure, divisional infrastructure, and provider characteristics. While many of the individual factors driving disparities are outside clinicians’ control, “there are some domains clinicians may be able to directly influence, such as provider characteristics, JIA treatment course, and possibly divisional infrastructure,” Harry noted, and the team appeared to choose goals that fell under domains within clinicians’ potential influence.

The research team focused their efforts on four areas: Consistent outcome documentation, application of JIA best practices, providing access to at-risk patients, and team awareness and agency.

As part of improving consistent outcome documentation, they integrated outcome metrics into data visualization tools so that gaps were more evident. Applying JIA best practices included standardizing their approach to assessing medication adherence and barriers, with changes to the JIA note templates in the electronic health record and updates to medication adherence handouts.

Providing access to at-risk patients included several components:

• Creating a population management team
• Defining a target population to engage with for earlier follow-up
• Using a monthly batch outreach to defined patients
• Having a coordinator or social worker reach out to those who don’t make appointments
• Using a new JIA/high disease activity video follow-up program.

Finally, team awareness and agency involved giving physicians monthly access to mean cJADAS values for their own patients and at the division level. They also held quarterly disparity mitigation workshops.

Although the institution’s JIA population grew 13%, from 776 to 878 patients, over the course of the study, from January 2023 to May 2024, there was minimal change in the characteristics of the patient population. By May 2024, two thirds of patients (68%) were women, and 23% had public insurance. The population included 67% non-Hispanic White, 9% Hispanic/Latino, 7% non-Hispanic Black, and 4% Asian patients.

One third of the patients (32%) had the oligoarticular subtype, and other subtypes included enthesitis-related at 16%, polyarticular rheumatoid factor (RF)–negative at 15%, systemic at 7%, psoriatic at 6%, undifferentiated at 5%, and polyarticular RF-positive at 4%; data on subtype were unavailable for 14%. Most of their patients (71%) were in a high or very high quintile of the Childhood Opportunity Index, and 12% were in a low or very low quintile.

 

Results of the Quality Improvement Project

As of May 2024, the team had reached most of the goals they had set in terms of individual metrics. They met their goal of having a complete cJADAS calculated in more than 80% of JIA visits each month. With a goal of having over 90% of JIA monthly visits include disease activity target attestations, they reached 95% by May.

They aimed to have over half of JIA monthly visits include documentation of medication adherence/barrier assessment, and 75% of monthly visits had one. For their monthly outreach goal for overdue visits, they aimed to contact more than 75% of patients within 30 days if they were newly overdue for a follow-up visit but had only reached 47% by May 2024. The team had also completed 154 Maintenance of Certification assessments by May.

From initiation of project planning in January 2023 through May 2024, the overall JIA patient population experienced an improvement in cJADAS from 2.9 to 2.54. In individual cJADAS components, the mean patient global score improved from 1.71 to 1.47, the physician global score improved from 0.81 to 0.75, and the joint count score improved from 0.71 to 0.68.

In the non-Hispanic Black population, the mean cJADAS improved from 5.06 in January 2023 to 4.31 in May 2024. Mean cJADAS in the non-Hispanic White population fell from 2.63 to 2.29. With a difference of 0.4 points fewer between the Black and White populations, the disparity gap closed by 17%.

One of the team’s next steps will be to focus on the Hispanic population in 2024-2025 by optimizing language services, working toward greater family involvement to better understand barriers to care, and ongoing population management.

Abel and Harry had no disclosures. No external funding was noted.

A version of this article appeared on Medscape.com.

WASHINGTON — A quality improvement project aimed at reducing racial disparities in juvenile idiopathic arthritis (JIA) led to a modest reduction in the overall clinical Juvenile Arthritis Disease Activity Score (cJADAS) and a 17% reduction in the disparity gap between Black and White patients, according to a study presented at the annual meeting of the American College of Rheumatology.

“Our work has led to initial progress in all groups, but we did not fully close the gap in outcomes,” Dori Abel, MD, MSHP, an attending rheumatologist at Children’s Hospital of Philadelphia in Pennsylvania, told attendees. But the project still revealed that it’s feasible to improve outcomes and reduce disparities with a “multipronged, equity-driven approach,” she said. “Stratifying data by demographic variables can reveal important differences in health care delivery and outcomes, catalyzing improvement efforts.”

Giya Harry, MD, MPH, MSc, an associate professor of pediatric rheumatology at Wake Forest University School of Medicine in Winston-Salem, North Carolina, was not involved in the study but praised both the effort and the progress made.

“The results are promising and suggest that with additional interventions targeting other key drivers, the team may be successful in completely eliminating the disparity in outcomes,” Harry said in an interview. “I applaud the hard work of Dr Abel and the other members of the team for doing the important work of characterizing the very complex issue of disparities in JIA outcomes across different race groups.” 

It will now be important to build upon what the physicians learned during this process, said Harry, also the chair of the Diversity, Equity, Inclusion, and Accessibility committee of the Childhood Arthritis and Rheumatology Research Alliance.

“Patience is needed as they cycle through interventions with an emphasis on other key drivers” of disparities, Harry said.

 

Targeting Factors That Clinicians Can Potentially Influence

In her presentation, Abel discussed the various barriers that interfere with patients’ ability to move up the “JIA escalator” of getting referred and diagnosed, starting treatment and getting control of the disease, and monitoring and managing the disease and flares. These barriers include difficulties with access, trust, finances, insurance, caregivers’ missed work, medication burden, side effects, system barriers, and exhaustion and depression among caregivers and patients.

These barriers then contribute to disparities in JIA outcomes. In the STOP-JIA study, for example, Black children had greater polyarthritis disease activity in the first year and greater odds of radiographic damage, Abel noted. At her own institution, despite a mean cJADAS of 2.9 for the whole population of patients with JIA, the average was 5.0 for non-Hispanic Black patients, compared with 2.6 for non-Hispanic White patients.

The team therefore developed and implemented a quality improvement initiative aimed at improving the overall mean cJADAS and narrowing the gap between Black and White patients. The goal was to reduce the mean cJADAS to 2.7 by July 2024 and simultaneously reduce the cJADAS in Black patients by 1.2 units, or 50% of the baseline disparity gap, without increasing the existing gap.

The team first explored the many overlapping and interacting drivers of disparities within the realms of community characteristics, JIA treatment course, patient/family characteristics, organizational infrastructure, divisional infrastructure, and provider characteristics. While many of the individual factors driving disparities are outside clinicians’ control, “there are some domains clinicians may be able to directly influence, such as provider characteristics, JIA treatment course, and possibly divisional infrastructure,” Harry noted, and the team appeared to choose goals that fell under domains within clinicians’ potential influence.

The research team focused their efforts on four areas: Consistent outcome documentation, application of JIA best practices, providing access to at-risk patients, and team awareness and agency.

As part of improving consistent outcome documentation, they integrated outcome metrics into data visualization tools so that gaps were more evident. Applying JIA best practices included standardizing their approach to assessing medication adherence and barriers, with changes to the JIA note templates in the electronic health record and updates to medication adherence handouts.

Providing access to at-risk patients included several components:

• Creating a population management team
• Defining a target population to engage with for earlier follow-up
• Using a monthly batch outreach to defined patients
• Having a coordinator or social worker reach out to those who don’t make appointments
• Using a new JIA/high disease activity video follow-up program.

Finally, team awareness and agency involved giving physicians monthly access to mean cJADAS values for their own patients and at the division level. They also held quarterly disparity mitigation workshops.

Although the institution’s JIA population grew 13%, from 776 to 878 patients, over the course of the study, from January 2023 to May 2024, there was minimal change in the characteristics of the patient population. By May 2024, two thirds of patients (68%) were women, and 23% had public insurance. The population included 67% non-Hispanic White, 9% Hispanic/Latino, 7% non-Hispanic Black, and 4% Asian patients.

One third of the patients (32%) had the oligoarticular subtype, and other subtypes included enthesitis-related at 16%, polyarticular rheumatoid factor (RF)–negative at 15%, systemic at 7%, psoriatic at 6%, undifferentiated at 5%, and polyarticular RF-positive at 4%; data on subtype were unavailable for 14%. Most of their patients (71%) were in a high or very high quintile of the Childhood Opportunity Index, and 12% were in a low or very low quintile.

 

Results of the Quality Improvement Project

As of May 2024, the team had reached most of the goals they had set in terms of individual metrics. They met their goal of having a complete cJADAS calculated in more than 80% of JIA visits each month. With a goal of having over 90% of JIA monthly visits include disease activity target attestations, they reached 95% by May.

They aimed to have over half of JIA monthly visits include documentation of medication adherence/barrier assessment, and 75% of monthly visits had one. For their monthly outreach goal for overdue visits, they aimed to contact more than 75% of patients within 30 days if they were newly overdue for a follow-up visit but had only reached 47% by May 2024. The team had also completed 154 Maintenance of Certification assessments by May.

From initiation of project planning in January 2023 through May 2024, the overall JIA patient population experienced an improvement in cJADAS from 2.9 to 2.54. In individual cJADAS components, the mean patient global score improved from 1.71 to 1.47, the physician global score improved from 0.81 to 0.75, and the joint count score improved from 0.71 to 0.68.

In the non-Hispanic Black population, the mean cJADAS improved from 5.06 in January 2023 to 4.31 in May 2024. Mean cJADAS in the non-Hispanic White population fell from 2.63 to 2.29. With a difference of 0.4 points fewer between the Black and White populations, the disparity gap closed by 17%.

One of the team’s next steps will be to focus on the Hispanic population in 2024-2025 by optimizing language services, working toward greater family involvement to better understand barriers to care, and ongoing population management.

Abel and Harry had no disclosures. No external funding was noted.

A version of this article appeared on Medscape.com.

WASHINGTON — A quality improvement project aimed at reducing racial disparities in juvenile idiopathic arthritis (JIA) led to a modest reduction in the overall clinical Juvenile Arthritis Disease Activity Score (cJADAS) and a 17% reduction in the disparity gap between Black and White patients, according to a study presented at the annual meeting of the American College of Rheumatology.

“Our work has led to initial progress in all groups, but we did not fully close the gap in outcomes,” Dori Abel, MD, MSHP, an attending rheumatologist at Children’s Hospital of Philadelphia in Pennsylvania, told attendees. But the project still revealed that it’s feasible to improve outcomes and reduce disparities with a “multipronged, equity-driven approach,” she said. “Stratifying data by demographic variables can reveal important differences in health care delivery and outcomes, catalyzing improvement efforts.”

Giya Harry, MD, MPH, MSc, an associate professor of pediatric rheumatology at Wake Forest University School of Medicine in Winston-Salem, North Carolina, was not involved in the study but praised both the effort and the progress made.

“The results are promising and suggest that with additional interventions targeting other key drivers, the team may be successful in completely eliminating the disparity in outcomes,” Harry said in an interview. “I applaud the hard work of Dr Abel and the other members of the team for doing the important work of characterizing the very complex issue of disparities in JIA outcomes across different race groups.” 

It will now be important to build upon what the physicians learned during this process, said Harry, also the chair of the Diversity, Equity, Inclusion, and Accessibility committee of the Childhood Arthritis and Rheumatology Research Alliance.

“Patience is needed as they cycle through interventions with an emphasis on other key drivers” of disparities, Harry said.

 

Targeting Factors That Clinicians Can Potentially Influence

In her presentation, Abel discussed the various barriers that interfere with patients’ ability to move up the “JIA escalator” of getting referred and diagnosed, starting treatment and getting control of the disease, and monitoring and managing the disease and flares. These barriers include difficulties with access, trust, finances, insurance, caregivers’ missed work, medication burden, side effects, system barriers, and exhaustion and depression among caregivers and patients.

These barriers then contribute to disparities in JIA outcomes. In the STOP-JIA study, for example, Black children had greater polyarthritis disease activity in the first year and greater odds of radiographic damage, Abel noted. At her own institution, despite a mean cJADAS of 2.9 for the whole population of patients with JIA, the average was 5.0 for non-Hispanic Black patients, compared with 2.6 for non-Hispanic White patients.

The team therefore developed and implemented a quality improvement initiative aimed at improving the overall mean cJADAS and narrowing the gap between Black and White patients. The goal was to reduce the mean cJADAS to 2.7 by July 2024 and simultaneously reduce the cJADAS in Black patients by 1.2 units, or 50% of the baseline disparity gap, without increasing the existing gap.

The team first explored the many overlapping and interacting drivers of disparities within the realms of community characteristics, JIA treatment course, patient/family characteristics, organizational infrastructure, divisional infrastructure, and provider characteristics. While many of the individual factors driving disparities are outside clinicians’ control, “there are some domains clinicians may be able to directly influence, such as provider characteristics, JIA treatment course, and possibly divisional infrastructure,” Harry noted, and the team appeared to choose goals that fell under domains within clinicians’ potential influence.

The research team focused their efforts on four areas: Consistent outcome documentation, application of JIA best practices, providing access to at-risk patients, and team awareness and agency.

As part of improving consistent outcome documentation, they integrated outcome metrics into data visualization tools so that gaps were more evident. Applying JIA best practices included standardizing their approach to assessing medication adherence and barriers, with changes to the JIA note templates in the electronic health record and updates to medication adherence handouts.

Providing access to at-risk patients included several components:

• Creating a population management team
• Defining a target population to engage with for earlier follow-up
• Using a monthly batch outreach to defined patients
• Having a coordinator or social worker reach out to those who don’t make appointments
• Using a new JIA/high disease activity video follow-up program.

Finally, team awareness and agency involved giving physicians monthly access to mean cJADAS values for their own patients and at the division level. They also held quarterly disparity mitigation workshops.

Although the institution’s JIA population grew 13%, from 776 to 878 patients, over the course of the study, from January 2023 to May 2024, there was minimal change in the characteristics of the patient population. By May 2024, two thirds of patients (68%) were women, and 23% had public insurance. The population included 67% non-Hispanic White, 9% Hispanic/Latino, 7% non-Hispanic Black, and 4% Asian patients.

One third of the patients (32%) had the oligoarticular subtype, and other subtypes included enthesitis-related at 16%, polyarticular rheumatoid factor (RF)–negative at 15%, systemic at 7%, psoriatic at 6%, undifferentiated at 5%, and polyarticular RF-positive at 4%; data on subtype were unavailable for 14%. Most of their patients (71%) were in a high or very high quintile of the Childhood Opportunity Index, and 12% were in a low or very low quintile.

 

Results of the Quality Improvement Project

As of May 2024, the team had reached most of the goals they had set in terms of individual metrics. They met their goal of having a complete cJADAS calculated in more than 80% of JIA visits each month. With a goal of having over 90% of JIA monthly visits include disease activity target attestations, they reached 95% by May.

They aimed to have over half of JIA monthly visits include documentation of medication adherence/barrier assessment, and 75% of monthly visits had one. For their monthly outreach goal for overdue visits, they aimed to contact more than 75% of patients within 30 days if they were newly overdue for a follow-up visit but had only reached 47% by May 2024. The team had also completed 154 Maintenance of Certification assessments by May.

From initiation of project planning in January 2023 through May 2024, the overall JIA patient population experienced an improvement in cJADAS from 2.9 to 2.54. In individual cJADAS components, the mean patient global score improved from 1.71 to 1.47, the physician global score improved from 0.81 to 0.75, and the joint count score improved from 0.71 to 0.68.

In the non-Hispanic Black population, the mean cJADAS improved from 5.06 in January 2023 to 4.31 in May 2024. Mean cJADAS in the non-Hispanic White population fell from 2.63 to 2.29. With a difference of 0.4 points fewer between the Black and White populations, the disparity gap closed by 17%.

One of the team’s next steps will be to focus on the Hispanic population in 2024-2025 by optimizing language services, working toward greater family involvement to better understand barriers to care, and ongoing population management.

Abel and Harry had no disclosures. No external funding was noted.

A version of this article appeared on Medscape.com.

WASHINGTON — Children who have systemic juvenile idiopathic arthritis with lung disease (sJIA-LD) have distinct biomarker profiles that may hold potential in eventually detecting LD earlier and identifying personalized treatment, according to research presented at the American College of Rheumatology (ACR) 2024 Annual Meeting.

Established risk factors for LD, which affects up to 1 in every 20 patients with sJIA, include being of a younger age, having more macrophage activation syndrome (MAS) episodes, and having more adverse reactions to biologics, Esraa Eloseily, MD, MS, an assistant professor of pediatrics at UT Southwestern Children’s Medical Center, Dallas, told attendees.

“The pathophysiology remains unclear and debate centers around elevated IL-18 [interleukin 18] and T-cell activation in association with HLA-DRB1*15/DRESS [drug reaction with eosinophilia and systemic symptoms] reactions to biologics, and thus, we have urgent unmet needs to understand the prevalence, the pathogenesis, disease biomarkers, and influence of biologics,” Eloseily said.

Their study confirmed that patients with LD tended to be younger and have more MAS. The researchers also found lower hemoglobin and higher white blood cell counts and platelets in patients with sJIA-LD, as well as a higher medication burden, particularly with steroids, biologics, and Janus kinase (JAK) inhibitors.

Randy Cron, MD, PhD, director of the Division of Pediatric Rheumatology at the University of Alabama at Birmingham, attended the presentation and noted that every additional piece of information is helpful in filling out the picture of what we know and can predict about sJIA-LD development.

“We’re all learning as we go, so the more people that study this, the better,” Cron told Medscape Medical News. “Even if it’s just seeing things that other groups have seen or really solidifying the risk factors for the development of lung disease, I think, at this point, that’s one of the most clinically relevant things: Do we screen? Who do we screen? Certainly, kids who have very young age of onset, children who develop macrophage activation syndrome, children who have high IL-18 levels.”

 

Study Results

The study compared 37 patients with sJIA-LD from 16 Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry sites with 141 patients with sJIA but without LD who had similar follow-up durations in the CARRA Registry.

Disease duration for patients with sJIA-LD was defined as the time from their initial sJIA diagnosis to their baseline sJIA-LD cohort visit, which was considered their index visit. In patients without LD, duration was from their enrollment in the CARRA Registry to their last CARRA Registry visit, which was considered their index visit.

The patients with sJIA-LD were significantly younger — a median age of 1 year — at onset of sJIA than those without LD, who had a median age of 5 years (P < .0019). The patients with sJIA-LD were also younger (median age, 7 years) at their index visit than those without LD (median age, 10 years) (P < .0001).

There were also significant differences in medication usage between those with and without LD. While 40.5% of patients with sJIA-LD were using steroids at their index visit, only 11.4% of those without LD were using steroids (P < .0001). Yet the mean dose of steroids was significantly lower in those with LD (5.45 mg/d) than in those without (20.7 mg/d). In addition, nearly half the patients with sJIA-LD had ever used cyclosporin A (45.7%) compared with 2.8% of those without LD (P < .0001), and 17.1% of patients with sJIA-LD had used mycophenolate mofetil compared with 0.7% of those without LD (P = .0002).

Similar disparities were seen for usage of biologics and JAK inhibitors: Anakinra (82.9% vs 56.7%; P = .0036), abatacept (8.6% vs 1.4%; P = .053), tofacitinib (57.1% vs 5.7%; P < .0001), ruxolitinib (25.7% vs 0%; P < .0001), baricitinib (8.6% vs 0%; P = .007), and emapalumab (23% vs 0.7%; P < .0001). Further, 5.7% of those with sJIA-LD had taken etoposide and 22.9% had received intravenous immunoglobulin compared with 0% and 4.3%, respectively, in those without LD (P = .04 and P = .001).

Laboratory parameters of patients with sJIA-LD were also significantly different from those of patients without LD, including a higher white blood cell count (8.8 × 109/L vs 8.1 × 109/L; P = .01), higher platelets (316.5 × 109/L vs 311.2 × 109/L; P = .03), and lower hemoglobin (11.5 g/dL vs 12.6 g/dL; P = .007). Ferritin levels trended nonsignificantly higher in patients with sJIA-LD (506 ng/mL vs 173.2 ng/mL; P = .09), and aspartate aminotransferase levels were significantly higher (37 U/L vs 28.72 U/L; P < .0001).

Patients’ overall well-being was “unexpectedly” higher in patients with sJIA-LD (P = .007), Eloseily noted, including the parent/patient rating (P = .027). However, more of the patients without LD had an excellent (61%) or very good (20.4%) health-related quality of life compared with those with LD (13% and 39%), and nearly one third of patients with sJIA-LD (30.4%) had only fair health-related quality of life compared with 5.5% without LD (P = .0002).

In line with known risk factors, most of the patients with sJIA-LD had a prior MAS episode (67.6%) compared with 10.6% of those without LD (P < .0001). Mortality was also higher in those with LD, two of whom died, whereas none without LD died (P = .04).

While existing biomarkers have been reported, they lack independent validation, Eloseily told attendees. Among the known key biomarkers are IL-18/interferon (IFN)-gamma axis, which are known to drive MAS and pulmonary inflammation, especially in those with MAS and LD; ICAM-5 and MMP-7, which is linked to fibrosis and tissue remodeling; and CCL11, CCL17, and GDF-15, which is linked to fibrosis and inflammation.

Because the CARRA Registry has limited availability of biosamples for most patients, the researchers used plasma samples from the FROST study for 27 patients with sJIA-LD and 46 patients without LD. When they compared 23 biomarkers between the groups, most of the known key biomarkers, as well as several other biomarkers, were significantly elevated in those with LD compared with in those without:

• MMP-7 (P = .001)
• IFN gamma (P = .008)
• CCL11 (P < .0001)
• CCL17 (P = .002)
• CCL15 (P < .0001)
• MCP-1 (P = .0003)
• MCP-3 (P = .02)
• CCL25 (P < .0001)
• CD25 (P < .0001)
• GDF-15 (P < .0001)
• TRAIL (P < .0001)
• IL-23 (P = .002)

They found that IL-18 only trended higher (P = .07), and there were not adequate data for ICAM-5.

The study was limited by the differences in disease duration between the compared groups and the limited availability of biosamples, which they only had from patients enrolled in the FROST study.

The research was funded by CARRA and the Arthritis Foundation. Eloseily reported no disclosures. Cron reported serving as an adviser for AbbVie/Abbott and Sobi, receiving grant funding and speaking and consulting fees from Pfizer, and receiving royalties from Springer.

 

A version of this article appeared on Medscape.com.

WASHINGTON — Children who have systemic juvenile idiopathic arthritis with lung disease (sJIA-LD) have distinct biomarker profiles that may hold potential in eventually detecting LD earlier and identifying personalized treatment, according to research presented at the American College of Rheumatology (ACR) 2024 Annual Meeting.

Established risk factors for LD, which affects up to 1 in every 20 patients with sJIA, include being of a younger age, having more macrophage activation syndrome (MAS) episodes, and having more adverse reactions to biologics, Esraa Eloseily, MD, MS, an assistant professor of pediatrics at UT Southwestern Children’s Medical Center, Dallas, told attendees.

“The pathophysiology remains unclear and debate centers around elevated IL-18 [interleukin 18] and T-cell activation in association with HLA-DRB1*15/DRESS [drug reaction with eosinophilia and systemic symptoms] reactions to biologics, and thus, we have urgent unmet needs to understand the prevalence, the pathogenesis, disease biomarkers, and influence of biologics,” Eloseily said.

Their study confirmed that patients with LD tended to be younger and have more MAS. The researchers also found lower hemoglobin and higher white blood cell counts and platelets in patients with sJIA-LD, as well as a higher medication burden, particularly with steroids, biologics, and Janus kinase (JAK) inhibitors.

Randy Cron, MD, PhD, director of the Division of Pediatric Rheumatology at the University of Alabama at Birmingham, attended the presentation and noted that every additional piece of information is helpful in filling out the picture of what we know and can predict about sJIA-LD development.

“We’re all learning as we go, so the more people that study this, the better,” Cron told Medscape Medical News. “Even if it’s just seeing things that other groups have seen or really solidifying the risk factors for the development of lung disease, I think, at this point, that’s one of the most clinically relevant things: Do we screen? Who do we screen? Certainly, kids who have very young age of onset, children who develop macrophage activation syndrome, children who have high IL-18 levels.”

 

Study Results

The study compared 37 patients with sJIA-LD from 16 Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry sites with 141 patients with sJIA but without LD who had similar follow-up durations in the CARRA Registry.

Disease duration for patients with sJIA-LD was defined as the time from their initial sJIA diagnosis to their baseline sJIA-LD cohort visit, which was considered their index visit. In patients without LD, duration was from their enrollment in the CARRA Registry to their last CARRA Registry visit, which was considered their index visit.

The patients with sJIA-LD were significantly younger — a median age of 1 year — at onset of sJIA than those without LD, who had a median age of 5 years (P < .0019). The patients with sJIA-LD were also younger (median age, 7 years) at their index visit than those without LD (median age, 10 years) (P < .0001).

There were also significant differences in medication usage between those with and without LD. While 40.5% of patients with sJIA-LD were using steroids at their index visit, only 11.4% of those without LD were using steroids (P < .0001). Yet the mean dose of steroids was significantly lower in those with LD (5.45 mg/d) than in those without (20.7 mg/d). In addition, nearly half the patients with sJIA-LD had ever used cyclosporin A (45.7%) compared with 2.8% of those without LD (P < .0001), and 17.1% of patients with sJIA-LD had used mycophenolate mofetil compared with 0.7% of those without LD (P = .0002).

Similar disparities were seen for usage of biologics and JAK inhibitors: Anakinra (82.9% vs 56.7%; P = .0036), abatacept (8.6% vs 1.4%; P = .053), tofacitinib (57.1% vs 5.7%; P < .0001), ruxolitinib (25.7% vs 0%; P < .0001), baricitinib (8.6% vs 0%; P = .007), and emapalumab (23% vs 0.7%; P < .0001). Further, 5.7% of those with sJIA-LD had taken etoposide and 22.9% had received intravenous immunoglobulin compared with 0% and 4.3%, respectively, in those without LD (P = .04 and P = .001).

Laboratory parameters of patients with sJIA-LD were also significantly different from those of patients without LD, including a higher white blood cell count (8.8 × 109/L vs 8.1 × 109/L; P = .01), higher platelets (316.5 × 109/L vs 311.2 × 109/L; P = .03), and lower hemoglobin (11.5 g/dL vs 12.6 g/dL; P = .007). Ferritin levels trended nonsignificantly higher in patients with sJIA-LD (506 ng/mL vs 173.2 ng/mL; P = .09), and aspartate aminotransferase levels were significantly higher (37 U/L vs 28.72 U/L; P < .0001).

Patients’ overall well-being was “unexpectedly” higher in patients with sJIA-LD (P = .007), Eloseily noted, including the parent/patient rating (P = .027). However, more of the patients without LD had an excellent (61%) or very good (20.4%) health-related quality of life compared with those with LD (13% and 39%), and nearly one third of patients with sJIA-LD (30.4%) had only fair health-related quality of life compared with 5.5% without LD (P = .0002).

In line with known risk factors, most of the patients with sJIA-LD had a prior MAS episode (67.6%) compared with 10.6% of those without LD (P < .0001). Mortality was also higher in those with LD, two of whom died, whereas none without LD died (P = .04).

While existing biomarkers have been reported, they lack independent validation, Eloseily told attendees. Among the known key biomarkers are IL-18/interferon (IFN)-gamma axis, which are known to drive MAS and pulmonary inflammation, especially in those with MAS and LD; ICAM-5 and MMP-7, which is linked to fibrosis and tissue remodeling; and CCL11, CCL17, and GDF-15, which is linked to fibrosis and inflammation.

Because the CARRA Registry has limited availability of biosamples for most patients, the researchers used plasma samples from the FROST study for 27 patients with sJIA-LD and 46 patients without LD. When they compared 23 biomarkers between the groups, most of the known key biomarkers, as well as several other biomarkers, were significantly elevated in those with LD compared with in those without:

• MMP-7 (P = .001)
• IFN gamma (P = .008)
• CCL11 (P < .0001)
• CCL17 (P = .002)
• CCL15 (P < .0001)
• MCP-1 (P = .0003)
• MCP-3 (P = .02)
• CCL25 (P < .0001)
• CD25 (P < .0001)
• GDF-15 (P < .0001)
• TRAIL (P < .0001)
• IL-23 (P = .002)

They found that IL-18 only trended higher (P = .07), and there were not adequate data for ICAM-5.

The study was limited by the differences in disease duration between the compared groups and the limited availability of biosamples, which they only had from patients enrolled in the FROST study.

The research was funded by CARRA and the Arthritis Foundation. Eloseily reported no disclosures. Cron reported serving as an adviser for AbbVie/Abbott and Sobi, receiving grant funding and speaking and consulting fees from Pfizer, and receiving royalties from Springer.

 

A version of this article appeared on Medscape.com.

WASHINGTON — Children who have systemic juvenile idiopathic arthritis with lung disease (sJIA-LD) have distinct biomarker profiles that may hold potential in eventually detecting LD earlier and identifying personalized treatment, according to research presented at the American College of Rheumatology (ACR) 2024 Annual Meeting.

Established risk factors for LD, which affects up to 1 in every 20 patients with sJIA, include being of a younger age, having more macrophage activation syndrome (MAS) episodes, and having more adverse reactions to biologics, Esraa Eloseily, MD, MS, an assistant professor of pediatrics at UT Southwestern Children’s Medical Center, Dallas, told attendees.

“The pathophysiology remains unclear and debate centers around elevated IL-18 [interleukin 18] and T-cell activation in association with HLA-DRB1*15/DRESS [drug reaction with eosinophilia and systemic symptoms] reactions to biologics, and thus, we have urgent unmet needs to understand the prevalence, the pathogenesis, disease biomarkers, and influence of biologics,” Eloseily said.

Their study confirmed that patients with LD tended to be younger and have more MAS. The researchers also found lower hemoglobin and higher white blood cell counts and platelets in patients with sJIA-LD, as well as a higher medication burden, particularly with steroids, biologics, and Janus kinase (JAK) inhibitors.

Randy Cron, MD, PhD, director of the Division of Pediatric Rheumatology at the University of Alabama at Birmingham, attended the presentation and noted that every additional piece of information is helpful in filling out the picture of what we know and can predict about sJIA-LD development.

“We’re all learning as we go, so the more people that study this, the better,” Cron told Medscape Medical News. “Even if it’s just seeing things that other groups have seen or really solidifying the risk factors for the development of lung disease, I think, at this point, that’s one of the most clinically relevant things: Do we screen? Who do we screen? Certainly, kids who have very young age of onset, children who develop macrophage activation syndrome, children who have high IL-18 levels.”

 

Study Results

The study compared 37 patients with sJIA-LD from 16 Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry sites with 141 patients with sJIA but without LD who had similar follow-up durations in the CARRA Registry.

Disease duration for patients with sJIA-LD was defined as the time from their initial sJIA diagnosis to their baseline sJIA-LD cohort visit, which was considered their index visit. In patients without LD, duration was from their enrollment in the CARRA Registry to their last CARRA Registry visit, which was considered their index visit.

The patients with sJIA-LD were significantly younger — a median age of 1 year — at onset of sJIA than those without LD, who had a median age of 5 years (P < .0019). The patients with sJIA-LD were also younger (median age, 7 years) at their index visit than those without LD (median age, 10 years) (P < .0001).

There were also significant differences in medication usage between those with and without LD. While 40.5% of patients with sJIA-LD were using steroids at their index visit, only 11.4% of those without LD were using steroids (P < .0001). Yet the mean dose of steroids was significantly lower in those with LD (5.45 mg/d) than in those without (20.7 mg/d). In addition, nearly half the patients with sJIA-LD had ever used cyclosporin A (45.7%) compared with 2.8% of those without LD (P < .0001), and 17.1% of patients with sJIA-LD had used mycophenolate mofetil compared with 0.7% of those without LD (P = .0002).

Similar disparities were seen for usage of biologics and JAK inhibitors: Anakinra (82.9% vs 56.7%; P = .0036), abatacept (8.6% vs 1.4%; P = .053), tofacitinib (57.1% vs 5.7%; P < .0001), ruxolitinib (25.7% vs 0%; P < .0001), baricitinib (8.6% vs 0%; P = .007), and emapalumab (23% vs 0.7%; P < .0001). Further, 5.7% of those with sJIA-LD had taken etoposide and 22.9% had received intravenous immunoglobulin compared with 0% and 4.3%, respectively, in those without LD (P = .04 and P = .001).

Laboratory parameters of patients with sJIA-LD were also significantly different from those of patients without LD, including a higher white blood cell count (8.8 × 109/L vs 8.1 × 109/L; P = .01), higher platelets (316.5 × 109/L vs 311.2 × 109/L; P = .03), and lower hemoglobin (11.5 g/dL vs 12.6 g/dL; P = .007). Ferritin levels trended nonsignificantly higher in patients with sJIA-LD (506 ng/mL vs 173.2 ng/mL; P = .09), and aspartate aminotransferase levels were significantly higher (37 U/L vs 28.72 U/L; P < .0001).

Patients’ overall well-being was “unexpectedly” higher in patients with sJIA-LD (P = .007), Eloseily noted, including the parent/patient rating (P = .027). However, more of the patients without LD had an excellent (61%) or very good (20.4%) health-related quality of life compared with those with LD (13% and 39%), and nearly one third of patients with sJIA-LD (30.4%) had only fair health-related quality of life compared with 5.5% without LD (P = .0002).

In line with known risk factors, most of the patients with sJIA-LD had a prior MAS episode (67.6%) compared with 10.6% of those without LD (P < .0001). Mortality was also higher in those with LD, two of whom died, whereas none without LD died (P = .04).

While existing biomarkers have been reported, they lack independent validation, Eloseily told attendees. Among the known key biomarkers are IL-18/interferon (IFN)-gamma axis, which are known to drive MAS and pulmonary inflammation, especially in those with MAS and LD; ICAM-5 and MMP-7, which is linked to fibrosis and tissue remodeling; and CCL11, CCL17, and GDF-15, which is linked to fibrosis and inflammation.

Because the CARRA Registry has limited availability of biosamples for most patients, the researchers used plasma samples from the FROST study for 27 patients with sJIA-LD and 46 patients without LD. When they compared 23 biomarkers between the groups, most of the known key biomarkers, as well as several other biomarkers, were significantly elevated in those with LD compared with in those without:

• MMP-7 (P = .001)
• IFN gamma (P = .008)
• CCL11 (P < .0001)
• CCL17 (P = .002)
• CCL15 (P < .0001)
• MCP-1 (P = .0003)
• MCP-3 (P = .02)
• CCL25 (P < .0001)
• CD25 (P < .0001)
• GDF-15 (P < .0001)
• TRAIL (P < .0001)
• IL-23 (P = .002)

They found that IL-18 only trended higher (P = .07), and there were not adequate data for ICAM-5.

The study was limited by the differences in disease duration between the compared groups and the limited availability of biosamples, which they only had from patients enrolled in the FROST study.

The research was funded by CARRA and the Arthritis Foundation. Eloseily reported no disclosures. Cron reported serving as an adviser for AbbVie/Abbott and Sobi, receiving grant funding and speaking and consulting fees from Pfizer, and receiving royalties from Springer.

 

A version of this article appeared on Medscape.com.

SAN DIEGO — The addition of the bispecific T-cell engager blinatumomab (Blincyto) to chemotherapy greatly boosted 3-year disease-free survival (DFS) in younger pediatric patients with newly diagnosed, standard-risk B-cell acute lymphoblastic leukemia (B-ALL), in a phase 3 randomized trial. 

Among pediatric patients with B-ALL followed for a mean of 2.5 years (1.6-3.2 years), 718 patients in the blinatumomab-plus-chemotherapy group had a 3-year DFS of 96.0 ± 1.2%, compared with 87.9 ± 2.1% of the 722 patients in the chemotherapy-only group, researchers reported at the American Society of Hematology (ASH) 2024 Annual Meeting.

“Our results demonstrate that blinatumomab added to chemotherapy represents a new treatment standard for most patients with NCI [National Cancer Institute] standard-risk [B-ALL],” said first author Rachel E. Rau, MD, Seattle Children’s Hospital, University of Washington, during a news briefing.

As Cynthia E. Dunbar, MD, chief of the Translational Stem Cell Biology Branch at the National Heart, Lung, and Blood Institute, noted in a news briefing: “B-cell ALL is the most common childhood cancer and one of the most treatable. However, some children still relapse following standard chemotherapy treatments and then have a much grimmer outcome.”

The AALL1731 study was initiated in 2019 with a recruitment goal of 2245 participants. The patients were over age 1 and less than 10 years, with an initial white blood cell count of < 50,000/μL and were considered to be standard risk–high or standard risk–average. 

The control group received standard-intensity chemotherapy (standard risk–average patients) or augmented Berlin-Frankfurt-Münster–based chemotherapy (standard risk–high patients). In addition, the blinatumomab groups received two cycles of the drug. 

Randomization was terminated in 2024 at 1440 patients because of the positive results. Patients had a median age of 4.3 years (2.8-6.4), 52.6% were boys, 26% were Hispanic, and 5% were non-Hispanic Black. 

The addition of blinatumomab improved DFS by 61% (hazard ratio, 0.39; 95% CI, 0.24-0.64; P < .0001). 

In the group of standard risk–average patients, 3-year DFS was 97.5±1.3% in the blinatumomab group vs 90.2±2.3% in the control group (HR, 0.33; 95% CI, 0.15-0.69). For standard risk–high patients, 3-year DFS was 94.1 ± 2.5% and 84.8 ± 3.8%, respectively. 

Six deaths occurred in remission, all in standard risk–high patients and none during blinatumomab cycles. Out of first courses of blinatumomab, 0.3% were associated with Grade 3 or higher cytokine release syndrome and 0.7% with seizures.

“We did note higher rates of subsequent sepsis and catheter-related infections in our standard risk–average patients who received blinatumomab,” Rau said. 

“The improvement in disease survival was secondary to significant reduction in bone marrow relapse,” Rau added. “We did not see a similar reduction in the more rare event of an isolated central nervous system relapse. This finding was not surprising given blinatumomab’s known limited activity in the central nervous system.”

Rau noted that there are two challenges in terms of access to blinatumomab: its cost, at about $225,000 per a 2023 report, and its administration. The drug is administered via 4-week-long infusions. “The delivery method is very cumbersome,” she said. 

“These are big problems that are going to take the combined efforts of pediatric oncologist cancer consortia and pharmaceutical industry partners as well as government agencies,” she said. Fortunately, she said, in June 2024 the Food and Drug Administration approved blinatumomab for adult and pediatric patients 1 month and older with CD19-positive Philadelphia chromosome–negative B-ALL in the consolidation phase of multiphase chemotherapy. 

“So it’s relatively easy, at least, to prescribe blinatumomab in the United States for our patients that we feel would benefit from it,” she said. 

As for method of delivery, Rau said easier-to-deliver formulations are in development. 

Rau has disclosed spousal employment (AbbVie), serving on advisory boards (Servier, Jazz), consulting, and receiving honoraria (Jazz). Other study authors report various disclosures including ties with Amgen, the maker of blinatumomab. Dunbar has reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

SAN DIEGO — The addition of the bispecific T-cell engager blinatumomab (Blincyto) to chemotherapy greatly boosted 3-year disease-free survival (DFS) in younger pediatric patients with newly diagnosed, standard-risk B-cell acute lymphoblastic leukemia (B-ALL), in a phase 3 randomized trial. 

Among pediatric patients with B-ALL followed for a mean of 2.5 years (1.6-3.2 years), 718 patients in the blinatumomab-plus-chemotherapy group had a 3-year DFS of 96.0 ± 1.2%, compared with 87.9 ± 2.1% of the 722 patients in the chemotherapy-only group, researchers reported at the American Society of Hematology (ASH) 2024 Annual Meeting.

“Our results demonstrate that blinatumomab added to chemotherapy represents a new treatment standard for most patients with NCI [National Cancer Institute] standard-risk [B-ALL],” said first author Rachel E. Rau, MD, Seattle Children’s Hospital, University of Washington, during a news briefing.

As Cynthia E. Dunbar, MD, chief of the Translational Stem Cell Biology Branch at the National Heart, Lung, and Blood Institute, noted in a news briefing: “B-cell ALL is the most common childhood cancer and one of the most treatable. However, some children still relapse following standard chemotherapy treatments and then have a much grimmer outcome.”

The AALL1731 study was initiated in 2019 with a recruitment goal of 2245 participants. The patients were over age 1 and less than 10 years, with an initial white blood cell count of < 50,000/μL and were considered to be standard risk–high or standard risk–average. 

The control group received standard-intensity chemotherapy (standard risk–average patients) or augmented Berlin-Frankfurt-Münster–based chemotherapy (standard risk–high patients). In addition, the blinatumomab groups received two cycles of the drug. 

Randomization was terminated in 2024 at 1440 patients because of the positive results. Patients had a median age of 4.3 years (2.8-6.4), 52.6% were boys, 26% were Hispanic, and 5% were non-Hispanic Black. 

The addition of blinatumomab improved DFS by 61% (hazard ratio, 0.39; 95% CI, 0.24-0.64; P < .0001). 

In the group of standard risk–average patients, 3-year DFS was 97.5±1.3% in the blinatumomab group vs 90.2±2.3% in the control group (HR, 0.33; 95% CI, 0.15-0.69). For standard risk–high patients, 3-year DFS was 94.1 ± 2.5% and 84.8 ± 3.8%, respectively. 

Six deaths occurred in remission, all in standard risk–high patients and none during blinatumomab cycles. Out of first courses of blinatumomab, 0.3% were associated with Grade 3 or higher cytokine release syndrome and 0.7% with seizures.

“We did note higher rates of subsequent sepsis and catheter-related infections in our standard risk–average patients who received blinatumomab,” Rau said. 

“The improvement in disease survival was secondary to significant reduction in bone marrow relapse,” Rau added. “We did not see a similar reduction in the more rare event of an isolated central nervous system relapse. This finding was not surprising given blinatumomab’s known limited activity in the central nervous system.”

Rau noted that there are two challenges in terms of access to blinatumomab: its cost, at about $225,000 per a 2023 report, and its administration. The drug is administered via 4-week-long infusions. “The delivery method is very cumbersome,” she said. 

“These are big problems that are going to take the combined efforts of pediatric oncologist cancer consortia and pharmaceutical industry partners as well as government agencies,” she said. Fortunately, she said, in June 2024 the Food and Drug Administration approved blinatumomab for adult and pediatric patients 1 month and older with CD19-positive Philadelphia chromosome–negative B-ALL in the consolidation phase of multiphase chemotherapy. 

“So it’s relatively easy, at least, to prescribe blinatumomab in the United States for our patients that we feel would benefit from it,” she said. 

As for method of delivery, Rau said easier-to-deliver formulations are in development. 

Rau has disclosed spousal employment (AbbVie), serving on advisory boards (Servier, Jazz), consulting, and receiving honoraria (Jazz). Other study authors report various disclosures including ties with Amgen, the maker of blinatumomab. Dunbar has reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

SAN DIEGO — The addition of the bispecific T-cell engager blinatumomab (Blincyto) to chemotherapy greatly boosted 3-year disease-free survival (DFS) in younger pediatric patients with newly diagnosed, standard-risk B-cell acute lymphoblastic leukemia (B-ALL), in a phase 3 randomized trial. 

Among pediatric patients with B-ALL followed for a mean of 2.5 years (1.6-3.2 years), 718 patients in the blinatumomab-plus-chemotherapy group had a 3-year DFS of 96.0 ± 1.2%, compared with 87.9 ± 2.1% of the 722 patients in the chemotherapy-only group, researchers reported at the American Society of Hematology (ASH) 2024 Annual Meeting.

“Our results demonstrate that blinatumomab added to chemotherapy represents a new treatment standard for most patients with NCI [National Cancer Institute] standard-risk [B-ALL],” said first author Rachel E. Rau, MD, Seattle Children’s Hospital, University of Washington, during a news briefing.

As Cynthia E. Dunbar, MD, chief of the Translational Stem Cell Biology Branch at the National Heart, Lung, and Blood Institute, noted in a news briefing: “B-cell ALL is the most common childhood cancer and one of the most treatable. However, some children still relapse following standard chemotherapy treatments and then have a much grimmer outcome.”

The AALL1731 study was initiated in 2019 with a recruitment goal of 2245 participants. The patients were over age 1 and less than 10 years, with an initial white blood cell count of < 50,000/μL and were considered to be standard risk–high or standard risk–average. 

The control group received standard-intensity chemotherapy (standard risk–average patients) or augmented Berlin-Frankfurt-Münster–based chemotherapy (standard risk–high patients). In addition, the blinatumomab groups received two cycles of the drug. 

Randomization was terminated in 2024 at 1440 patients because of the positive results. Patients had a median age of 4.3 years (2.8-6.4), 52.6% were boys, 26% were Hispanic, and 5% were non-Hispanic Black. 

The addition of blinatumomab improved DFS by 61% (hazard ratio, 0.39; 95% CI, 0.24-0.64; P < .0001). 

In the group of standard risk–average patients, 3-year DFS was 97.5±1.3% in the blinatumomab group vs 90.2±2.3% in the control group (HR, 0.33; 95% CI, 0.15-0.69). For standard risk–high patients, 3-year DFS was 94.1 ± 2.5% and 84.8 ± 3.8%, respectively. 

Six deaths occurred in remission, all in standard risk–high patients and none during blinatumomab cycles. Out of first courses of blinatumomab, 0.3% were associated with Grade 3 or higher cytokine release syndrome and 0.7% with seizures.

“We did note higher rates of subsequent sepsis and catheter-related infections in our standard risk–average patients who received blinatumomab,” Rau said. 

“The improvement in disease survival was secondary to significant reduction in bone marrow relapse,” Rau added. “We did not see a similar reduction in the more rare event of an isolated central nervous system relapse. This finding was not surprising given blinatumomab’s known limited activity in the central nervous system.”

Rau noted that there are two challenges in terms of access to blinatumomab: its cost, at about $225,000 per a 2023 report, and its administration. The drug is administered via 4-week-long infusions. “The delivery method is very cumbersome,” she said. 

“These are big problems that are going to take the combined efforts of pediatric oncologist cancer consortia and pharmaceutical industry partners as well as government agencies,” she said. Fortunately, she said, in June 2024 the Food and Drug Administration approved blinatumomab for adult and pediatric patients 1 month and older with CD19-positive Philadelphia chromosome–negative B-ALL in the consolidation phase of multiphase chemotherapy. 

“So it’s relatively easy, at least, to prescribe blinatumomab in the United States for our patients that we feel would benefit from it,” she said. 

As for method of delivery, Rau said easier-to-deliver formulations are in development. 

Rau has disclosed spousal employment (AbbVie), serving on advisory boards (Servier, Jazz), consulting, and receiving honoraria (Jazz). Other study authors report various disclosures including ties with Amgen, the maker of blinatumomab. Dunbar has reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Practitioners providing care to children are familiar with the childhood immunization schedule and routinely administer varicella vaccine at the 12-month and 4- to 5-year visits. However, when is the last time most of us or any of the current trainees have seen a case?

Briefly, varicella is a highly contagious disease caused by varicella-zoster virus (VZV). It is characterized by a generalized pruritic erythematous rash in various stages of development beginning as macules, progressing to papules, and ultimately becoming vesicular lesions on an erythematous base (“dewdrop on a rose petal”) and resolves with crusting of the lesion (Figure 1). It has an incubation period of 10-21 days with symptoms usually developing within 14-16 days after exposure. The vesicular rash must be differentiated from enterovirus, Staphylococcus aureus, contact dermatitis, or insect bites, which initially may be difficult. Approximately 50% of children can have symptoms including fever, malaise, anorexia, headache, and occasionally, mild abdominal pain in the 24-48 hours prior to the appearance of rash. Lesions usually first appear on the scalp, face, or trunk in successive crops over several days. A person with varicella has lesions in various stages. 

In a normal host, new vesicle formation usually stops within 4 days, and most lesions have fully crusted by day 6. VZV establishes latency in sensory ganglia and may reactivate years or decades later to cause herpes zoster (HZ). Most healthy children with varicella recover without sequelae so the disease is generally regarded as benign. However, varicella can lead to serious complications and deaths in healthy as well as immunocompromised persons. 

Complications of Varicella: bacterial superinfection of skin lesions most often with Streptococcus pyogenes or S aureus manifested as cellulitis, myositis, or necrotizing fasciitis; neurologic complications include cerebellar ataxia and encephalitis with the latter seen most often in adults. Pneumonia occurs most often in adults, especially those infected during pregnancy. Another concern, infection during the first 20 weeks of pregnancy can lead to fetal death or severe birth defects, including limb hypoplasia, cutaneous scarring, ocular abnormalities, and central nervous system damage (congenital varicella syndrome). 

The risk for development of severe disseminated disease was first noted in the 1960s as treatments for leukemia in children improved. They were surviving their cancer only to develop severe and often fatal varicella. Today it is recognized that development of disseminated disease is a risk for all infected persons with impaired T cell function, malignancies, HIV, or receiving immunosuppressive therapy.

Reye’s syndrome is rarely seen today since taking salicylates while infected with VZV was identified as a predisposing factor for development. 

VZV is only found in humans and transmission is person to person or airborne. The secondary household attack rate is approximately 90%. In contrast, the secondary attack rates in classrooms may be as low as 12%-33%. Transmission rates in the tropics for unexplained reasons are also lower. 

Vaccine History: Why do we rarely see this disease anymore? Varicella, a live attenuated vaccine, was developed in 1974 by Dr. Michiaki Takahashi. It remains the only vaccine directed against a herpes group virus. In 1979, the Collaborative Varicella Vaccine Study Group was established at the National Institutes of Health (NIH) and additional safety and efficacy trials were conducted in the United States initially in leukemic patients in remission and later in healthy children, which supported Takahashi’s data. Licensure of varicella vaccine was granted in 1995. That same year, due to continuing disease and societal burden, the United States was the first country to incorporate varicella into the routine childhood immunization schedule, which resulted in significant reductions in cases. To further improve control of varicella, in 2007 vaccine recommendations were revised and a routine two-dose schedule was implemented. The impact of varicella disease pre- and post-vaccine licensure is illustrated in Figure 2. Not listed, is that in the pre-vaccine era, there were approximately 44 cases of congenital varicella syndrome annually. 

As of 2023 only 23% (45/195) of nations routinely administer this vaccine and 4% (8/195) have restricted recommendations. The remaining 73% of countries do not offer the vaccine, including all countries on the African continent, and Cuba, Guatemala, Haiti, Honduras, India, Jordan, Lebanon, Philippines, Portugal, and Venezuela to list a few. 

Varicella Outbreak: In October 2022, New York City (NYC) identified a varicella outbreak primarily involving persons who recently migrated from Central and South America and lived in a shelter in NYC or residential facility (n = 105); the outbreak is ongoing. As of March 8, 2024, 873 cases (53%) were among children aged 4-18 years and 91.9% had no documentation of varicella vaccine at time of symptom onset. There were 28 hospitalizations, and no deaths reported. The most common sources of transmission were the residential facilities (41.3%) and importation or possible importation (39.4%). School transmission accounted for only 1.2% of cases. 

Most migrants arrived from countries where varicella vaccination is not part of the routine childhood immunization schedule. Although most cases occurred in children, almost 30% occurred in adults. Many of the migrants arrived from tropical countries where susceptibility rates are also higher in adults. This outbreak is a reminder of the importance of limiting disease transmission by maintaining high vaccination rates. To curtail this outbreak, approximately 27,000 doses of varicella vaccine were administered to the arriving migrants. In addition, MMR, COVID-19, influenza, and all routine pediatric vaccines required for school entry were administered. Temporary closure of the residential facilities were required. Education was provided to residents regarding immunizations as well as assistance to help them establish a primary care home. Multiple agencies were mobilized to successfully coordinate these efforts. 

 

Take Home Message

1. Each country has its own routine immunization schedule. It may not include all vaccines recommended in the US schedule. When questioned I’m frequently told that immunizations are up to date, only to review records and find they are not, especially when it is related to MMR. It is often administered at 9 months and/or MR or MM is administered depending on the country. As reported here, varicella is a routine vaccine in only 45 countries.

2. To prevent vaccine preventable disease outbreaks and limit further transmission, high immunization coverage rates must be sustained.

3. Once an outbreak has been identified, the infrastructure to manage and contain it must already be established. In most instances there will be a need for a rapid and often large-scale effort involving multiple agencies including local health care providers.

4. Not all diseases are reportable. Only deaths by varicella are nationally notifiable. Otherwise, cases are reported voluntarily. As of November 2, 2024, there have been 5,157 cases of varicella reported, excluding any cases from NYC. 

 

Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She said she had no relevant financial disclosures.

Suggested Reading

CDC. Nationally Notifiable Infectious Diseases and Conditions, United States: Weekly Tables. https://wonder.cdc.gov/nndss/nndss_weekly_tables_menu.asp.

Graham KA et al. Varicella Outbreak Among Recent Arrivals to New York City, 2022-2024. MMWR Morb Mortal Wkly Rep. 2024 May 30;73(21):478-483. doi: 10.15585/mmwr.mm7321a1.

Marin M et al. Health and Economic Impact of the United States Varicella Vaccination Program, 1996-2020. J Infect Dis. 2022 Oct 21;226(Suppl 4):S463-S469. doi: 10.1093/infdis/jiac271.

Varicella-Zoster Virus Infections in Kimberkin DW et al, eds. Red Book: 2024 Report of the Committee on Infectious Diseases, 33rd Edition. American Academy of Pediatrics, 2024:938-951. https://www.aap.org/Red-Book-2024-Report-of-the-Committee-on-Infectious-Diseases-33rd-Edition-Paperback?srsltid=AfmBOoqyF60rR9ZwQ5jA8AouNhtRRTyPLnc_r7HWw7JVYV8v33Hr2vQS.

Practitioners providing care to children are familiar with the childhood immunization schedule and routinely administer varicella vaccine at the 12-month and 4- to 5-year visits. However, when is the last time most of us or any of the current trainees have seen a case?

Briefly, varicella is a highly contagious disease caused by varicella-zoster virus (VZV). It is characterized by a generalized pruritic erythematous rash in various stages of development beginning as macules, progressing to papules, and ultimately becoming vesicular lesions on an erythematous base (“dewdrop on a rose petal”) and resolves with crusting of the lesion (Figure 1). It has an incubation period of 10-21 days with symptoms usually developing within 14-16 days after exposure. The vesicular rash must be differentiated from enterovirus, Staphylococcus aureus, contact dermatitis, or insect bites, which initially may be difficult. Approximately 50% of children can have symptoms including fever, malaise, anorexia, headache, and occasionally, mild abdominal pain in the 24-48 hours prior to the appearance of rash. Lesions usually first appear on the scalp, face, or trunk in successive crops over several days. A person with varicella has lesions in various stages. 

In a normal host, new vesicle formation usually stops within 4 days, and most lesions have fully crusted by day 6. VZV establishes latency in sensory ganglia and may reactivate years or decades later to cause herpes zoster (HZ). Most healthy children with varicella recover without sequelae so the disease is generally regarded as benign. However, varicella can lead to serious complications and deaths in healthy as well as immunocompromised persons. 

Complications of Varicella: bacterial superinfection of skin lesions most often with Streptococcus pyogenes or S aureus manifested as cellulitis, myositis, or necrotizing fasciitis; neurologic complications include cerebellar ataxia and encephalitis with the latter seen most often in adults. Pneumonia occurs most often in adults, especially those infected during pregnancy. Another concern, infection during the first 20 weeks of pregnancy can lead to fetal death or severe birth defects, including limb hypoplasia, cutaneous scarring, ocular abnormalities, and central nervous system damage (congenital varicella syndrome). 

The risk for development of severe disseminated disease was first noted in the 1960s as treatments for leukemia in children improved. They were surviving their cancer only to develop severe and often fatal varicella. Today it is recognized that development of disseminated disease is a risk for all infected persons with impaired T cell function, malignancies, HIV, or receiving immunosuppressive therapy.

Reye’s syndrome is rarely seen today since taking salicylates while infected with VZV was identified as a predisposing factor for development. 

VZV is only found in humans and transmission is person to person or airborne. The secondary household attack rate is approximately 90%. In contrast, the secondary attack rates in classrooms may be as low as 12%-33%. Transmission rates in the tropics for unexplained reasons are also lower. 

Vaccine History: Why do we rarely see this disease anymore? Varicella, a live attenuated vaccine, was developed in 1974 by Dr. Michiaki Takahashi. It remains the only vaccine directed against a herpes group virus. In 1979, the Collaborative Varicella Vaccine Study Group was established at the National Institutes of Health (NIH) and additional safety and efficacy trials were conducted in the United States initially in leukemic patients in remission and later in healthy children, which supported Takahashi’s data. Licensure of varicella vaccine was granted in 1995. That same year, due to continuing disease and societal burden, the United States was the first country to incorporate varicella into the routine childhood immunization schedule, which resulted in significant reductions in cases. To further improve control of varicella, in 2007 vaccine recommendations were revised and a routine two-dose schedule was implemented. The impact of varicella disease pre- and post-vaccine licensure is illustrated in Figure 2. Not listed, is that in the pre-vaccine era, there were approximately 44 cases of congenital varicella syndrome annually. 

As of 2023 only 23% (45/195) of nations routinely administer this vaccine and 4% (8/195) have restricted recommendations. The remaining 73% of countries do not offer the vaccine, including all countries on the African continent, and Cuba, Guatemala, Haiti, Honduras, India, Jordan, Lebanon, Philippines, Portugal, and Venezuela to list a few. 

Varicella Outbreak: In October 2022, New York City (NYC) identified a varicella outbreak primarily involving persons who recently migrated from Central and South America and lived in a shelter in NYC or residential facility (n = 105); the outbreak is ongoing. As of March 8, 2024, 873 cases (53%) were among children aged 4-18 years and 91.9% had no documentation of varicella vaccine at time of symptom onset. There were 28 hospitalizations, and no deaths reported. The most common sources of transmission were the residential facilities (41.3%) and importation or possible importation (39.4%). School transmission accounted for only 1.2% of cases. 

Most migrants arrived from countries where varicella vaccination is not part of the routine childhood immunization schedule. Although most cases occurred in children, almost 30% occurred in adults. Many of the migrants arrived from tropical countries where susceptibility rates are also higher in adults. This outbreak is a reminder of the importance of limiting disease transmission by maintaining high vaccination rates. To curtail this outbreak, approximately 27,000 doses of varicella vaccine were administered to the arriving migrants. In addition, MMR, COVID-19, influenza, and all routine pediatric vaccines required for school entry were administered. Temporary closure of the residential facilities were required. Education was provided to residents regarding immunizations as well as assistance to help them establish a primary care home. Multiple agencies were mobilized to successfully coordinate these efforts. 

 

Take Home Message

1. Each country has its own routine immunization schedule. It may not include all vaccines recommended in the US schedule. When questioned I’m frequently told that immunizations are up to date, only to review records and find they are not, especially when it is related to MMR. It is often administered at 9 months and/or MR or MM is administered depending on the country. As reported here, varicella is a routine vaccine in only 45 countries.

2. To prevent vaccine preventable disease outbreaks and limit further transmission, high immunization coverage rates must be sustained.

3. Once an outbreak has been identified, the infrastructure to manage and contain it must already be established. In most instances there will be a need for a rapid and often large-scale effort involving multiple agencies including local health care providers.

4. Not all diseases are reportable. Only deaths by varicella are nationally notifiable. Otherwise, cases are reported voluntarily. As of November 2, 2024, there have been 5,157 cases of varicella reported, excluding any cases from NYC. 

 

Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She said she had no relevant financial disclosures.

Suggested Reading

CDC. Nationally Notifiable Infectious Diseases and Conditions, United States: Weekly Tables. https://wonder.cdc.gov/nndss/nndss_weekly_tables_menu.asp.

Graham KA et al. Varicella Outbreak Among Recent Arrivals to New York City, 2022-2024. MMWR Morb Mortal Wkly Rep. 2024 May 30;73(21):478-483. doi: 10.15585/mmwr.mm7321a1.

Marin M et al. Health and Economic Impact of the United States Varicella Vaccination Program, 1996-2020. J Infect Dis. 2022 Oct 21;226(Suppl 4):S463-S469. doi: 10.1093/infdis/jiac271.

Varicella-Zoster Virus Infections in Kimberkin DW et al, eds. Red Book: 2024 Report of the Committee on Infectious Diseases, 33rd Edition. American Academy of Pediatrics, 2024:938-951. https://www.aap.org/Red-Book-2024-Report-of-the-Committee-on-Infectious-Diseases-33rd-Edition-Paperback?srsltid=AfmBOoqyF60rR9ZwQ5jA8AouNhtRRTyPLnc_r7HWw7JVYV8v33Hr2vQS.

Practitioners providing care to children are familiar with the childhood immunization schedule and routinely administer varicella vaccine at the 12-month and 4- to 5-year visits. However, when is the last time most of us or any of the current trainees have seen a case?

Briefly, varicella is a highly contagious disease caused by varicella-zoster virus (VZV). It is characterized by a generalized pruritic erythematous rash in various stages of development beginning as macules, progressing to papules, and ultimately becoming vesicular lesions on an erythematous base (“dewdrop on a rose petal”) and resolves with crusting of the lesion (Figure 1). It has an incubation period of 10-21 days with symptoms usually developing within 14-16 days after exposure. The vesicular rash must be differentiated from enterovirus, Staphylococcus aureus, contact dermatitis, or insect bites, which initially may be difficult. Approximately 50% of children can have symptoms including fever, malaise, anorexia, headache, and occasionally, mild abdominal pain in the 24-48 hours prior to the appearance of rash. Lesions usually first appear on the scalp, face, or trunk in successive crops over several days. A person with varicella has lesions in various stages. 

In a normal host, new vesicle formation usually stops within 4 days, and most lesions have fully crusted by day 6. VZV establishes latency in sensory ganglia and may reactivate years or decades later to cause herpes zoster (HZ). Most healthy children with varicella recover without sequelae so the disease is generally regarded as benign. However, varicella can lead to serious complications and deaths in healthy as well as immunocompromised persons. 

Complications of Varicella: bacterial superinfection of skin lesions most often with Streptococcus pyogenes or S aureus manifested as cellulitis, myositis, or necrotizing fasciitis; neurologic complications include cerebellar ataxia and encephalitis with the latter seen most often in adults. Pneumonia occurs most often in adults, especially those infected during pregnancy. Another concern, infection during the first 20 weeks of pregnancy can lead to fetal death or severe birth defects, including limb hypoplasia, cutaneous scarring, ocular abnormalities, and central nervous system damage (congenital varicella syndrome). 

The risk for development of severe disseminated disease was first noted in the 1960s as treatments for leukemia in children improved. They were surviving their cancer only to develop severe and often fatal varicella. Today it is recognized that development of disseminated disease is a risk for all infected persons with impaired T cell function, malignancies, HIV, or receiving immunosuppressive therapy.

Reye’s syndrome is rarely seen today since taking salicylates while infected with VZV was identified as a predisposing factor for development. 

VZV is only found in humans and transmission is person to person or airborne. The secondary household attack rate is approximately 90%. In contrast, the secondary attack rates in classrooms may be as low as 12%-33%. Transmission rates in the tropics for unexplained reasons are also lower. 

Vaccine History: Why do we rarely see this disease anymore? Varicella, a live attenuated vaccine, was developed in 1974 by Dr. Michiaki Takahashi. It remains the only vaccine directed against a herpes group virus. In 1979, the Collaborative Varicella Vaccine Study Group was established at the National Institutes of Health (NIH) and additional safety and efficacy trials were conducted in the United States initially in leukemic patients in remission and later in healthy children, which supported Takahashi’s data. Licensure of varicella vaccine was granted in 1995. That same year, due to continuing disease and societal burden, the United States was the first country to incorporate varicella into the routine childhood immunization schedule, which resulted in significant reductions in cases. To further improve control of varicella, in 2007 vaccine recommendations were revised and a routine two-dose schedule was implemented. The impact of varicella disease pre- and post-vaccine licensure is illustrated in Figure 2. Not listed, is that in the pre-vaccine era, there were approximately 44 cases of congenital varicella syndrome annually. 

As of 2023 only 23% (45/195) of nations routinely administer this vaccine and 4% (8/195) have restricted recommendations. The remaining 73% of countries do not offer the vaccine, including all countries on the African continent, and Cuba, Guatemala, Haiti, Honduras, India, Jordan, Lebanon, Philippines, Portugal, and Venezuela to list a few. 

Varicella Outbreak: In October 2022, New York City (NYC) identified a varicella outbreak primarily involving persons who recently migrated from Central and South America and lived in a shelter in NYC or residential facility (n = 105); the outbreak is ongoing. As of March 8, 2024, 873 cases (53%) were among children aged 4-18 years and 91.9% had no documentation of varicella vaccine at time of symptom onset. There were 28 hospitalizations, and no deaths reported. The most common sources of transmission were the residential facilities (41.3%) and importation or possible importation (39.4%). School transmission accounted for only 1.2% of cases. 

Most migrants arrived from countries where varicella vaccination is not part of the routine childhood immunization schedule. Although most cases occurred in children, almost 30% occurred in adults. Many of the migrants arrived from tropical countries where susceptibility rates are also higher in adults. This outbreak is a reminder of the importance of limiting disease transmission by maintaining high vaccination rates. To curtail this outbreak, approximately 27,000 doses of varicella vaccine were administered to the arriving migrants. In addition, MMR, COVID-19, influenza, and all routine pediatric vaccines required for school entry were administered. Temporary closure of the residential facilities were required. Education was provided to residents regarding immunizations as well as assistance to help them establish a primary care home. Multiple agencies were mobilized to successfully coordinate these efforts. 

 

Take Home Message

1. Each country has its own routine immunization schedule. It may not include all vaccines recommended in the US schedule. When questioned I’m frequently told that immunizations are up to date, only to review records and find they are not, especially when it is related to MMR. It is often administered at 9 months and/or MR or MM is administered depending on the country. As reported here, varicella is a routine vaccine in only 45 countries.

2. To prevent vaccine preventable disease outbreaks and limit further transmission, high immunization coverage rates must be sustained.

3. Once an outbreak has been identified, the infrastructure to manage and contain it must already be established. In most instances there will be a need for a rapid and often large-scale effort involving multiple agencies including local health care providers.

4. Not all diseases are reportable. Only deaths by varicella are nationally notifiable. Otherwise, cases are reported voluntarily. As of November 2, 2024, there have been 5,157 cases of varicella reported, excluding any cases from NYC. 

 

Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She said she had no relevant financial disclosures.

Suggested Reading

CDC. Nationally Notifiable Infectious Diseases and Conditions, United States: Weekly Tables. https://wonder.cdc.gov/nndss/nndss_weekly_tables_menu.asp.

Graham KA et al. Varicella Outbreak Among Recent Arrivals to New York City, 2022-2024. MMWR Morb Mortal Wkly Rep. 2024 May 30;73(21):478-483. doi: 10.15585/mmwr.mm7321a1.

Marin M et al. Health and Economic Impact of the United States Varicella Vaccination Program, 1996-2020. J Infect Dis. 2022 Oct 21;226(Suppl 4):S463-S469. doi: 10.1093/infdis/jiac271.

Varicella-Zoster Virus Infections in Kimberkin DW et al, eds. Red Book: 2024 Report of the Committee on Infectious Diseases, 33rd Edition. American Academy of Pediatrics, 2024:938-951. https://www.aap.org/Red-Book-2024-Report-of-the-Committee-on-Infectious-Diseases-33rd-Edition-Paperback?srsltid=AfmBOoqyF60rR9ZwQ5jA8AouNhtRRTyPLnc_r7HWw7JVYV8v33Hr2vQS.

The answer one gets often depends on how one crafts the question. For example, Jeffrey D. Johnson PhD, a professor of communications at Portland State University in Oregon has found that if patients are asked “Is there something else you would like to address today?” 80% had their unmet questions addressed. However, if the question was worded “Is there anything else ...?” Very few had their unmet concerns addressed.

I recently encountered two studies that provide another striking example of how differently structured questions aimed at same topic can result in dramatically different results. In this case both studies used one database, the UK Biobank cohort study which contains “de-identified genetic, lifestyle, and health information” collected from a half million adults in the UK. A subgroup of nearly 90,000 who had undergone a week long activity measurement using a wrist accelerometer was the focus of both groups of investigators who asked the same broad question “What is the relationship between physical activity and disease?”

 

The first study I found has already received some publicity in the lay press and dealt with those individuals who, for a variety of reasons, pack all of their exercise into just a few days, usually the weekend, aka weekend warriors. The investigators found that when compared with generally inactive individuals those who were able to achieve activity volumes that met current guidelines were at lower risk for more than 200 diseases, particularly those that were cardiac based. I guess that shouldn’t surprise us. The finding that has received most of the publicity to date in the lay press was that “Associations were similar whether the activity followed a weekend warrior pattern or was spread out evenly through the week.”

The second study, using the same database, found that those individuals who spent more than 10.6 hours per day sitting had 60% an increased risk of heart failure and cardiovascular related death. And, here’s the real news, that risk remained even in people who were otherwise physically active.

I suspect these two groups of investigators, both associated with Harvard-related institutions, knew of each other’s work and would agree that their findings are not incompatible. However, it is interesting that, when presented with the same database, one group chose to focus its attention on the exercise end of the spectrum while the other looked at the effect of inactivity. 

I have always tried to include a “healthy” amount of exercise in my day. However, more recently my professional interest has been drawn to the increasing number of studies I read that deal with the risks of inactivity and sedentarism. For example, just in the last 2 years I have written about a study in children that showed that sedentary time is responsible for 70% of the total increase in cholesterol as children advance into young adulthood. Another study in adults found that every 2-hour increase in sedentary behavior was associated with a 12% decrease in the patient’s likelihood of achieving healthy aging.

If I were asked to place relative values on these two studies, I would say that the study highlighting the risk of prolonged sitting is potentially far more relevant to the population at large, which is for the most part sedentary. Of course, while I have no data to support my contention, I see the weekend warrior population as a niche group.

So what are the take-home messages from these two studies? One is for the weekend warrior. “You can take some comfort in the results that support your exercise schedule but don’t feel too comfortable about it if most of the week you are sitting at a desk.” 

For the rest of us — whether we are pediatricians, family practitioners, or internists — the message is to ease off our messaging on exercise and spend more energy getting our patients off their rear ends. It’s beginning to feel like we should be including accelerometers in our regular diagnostic and therapeutic weaponry. Sending home patients with a Holter cardiac monitor has become commonplace. We should be sending more folks home with accelerometers or asking the more affluent to share the data from their smart watches. “You’ve been bragging about your “steps. Show me your sitting time.”

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

The answer one gets often depends on how one crafts the question. For example, Jeffrey D. Johnson PhD, a professor of communications at Portland State University in Oregon has found that if patients are asked “Is there something else you would like to address today?” 80% had their unmet questions addressed. However, if the question was worded “Is there anything else ...?” Very few had their unmet concerns addressed.

I recently encountered two studies that provide another striking example of how differently structured questions aimed at same topic can result in dramatically different results. In this case both studies used one database, the UK Biobank cohort study which contains “de-identified genetic, lifestyle, and health information” collected from a half million adults in the UK. A subgroup of nearly 90,000 who had undergone a week long activity measurement using a wrist accelerometer was the focus of both groups of investigators who asked the same broad question “What is the relationship between physical activity and disease?”

 

The first study I found has already received some publicity in the lay press and dealt with those individuals who, for a variety of reasons, pack all of their exercise into just a few days, usually the weekend, aka weekend warriors. The investigators found that when compared with generally inactive individuals those who were able to achieve activity volumes that met current guidelines were at lower risk for more than 200 diseases, particularly those that were cardiac based. I guess that shouldn’t surprise us. The finding that has received most of the publicity to date in the lay press was that “Associations were similar whether the activity followed a weekend warrior pattern or was spread out evenly through the week.”

The second study, using the same database, found that those individuals who spent more than 10.6 hours per day sitting had 60% an increased risk of heart failure and cardiovascular related death. And, here’s the real news, that risk remained even in people who were otherwise physically active.

I suspect these two groups of investigators, both associated with Harvard-related institutions, knew of each other’s work and would agree that their findings are not incompatible. However, it is interesting that, when presented with the same database, one group chose to focus its attention on the exercise end of the spectrum while the other looked at the effect of inactivity. 

I have always tried to include a “healthy” amount of exercise in my day. However, more recently my professional interest has been drawn to the increasing number of studies I read that deal with the risks of inactivity and sedentarism. For example, just in the last 2 years I have written about a study in children that showed that sedentary time is responsible for 70% of the total increase in cholesterol as children advance into young adulthood. Another study in adults found that every 2-hour increase in sedentary behavior was associated with a 12% decrease in the patient’s likelihood of achieving healthy aging.

If I were asked to place relative values on these two studies, I would say that the study highlighting the risk of prolonged sitting is potentially far more relevant to the population at large, which is for the most part sedentary. Of course, while I have no data to support my contention, I see the weekend warrior population as a niche group.

So what are the take-home messages from these two studies? One is for the weekend warrior. “You can take some comfort in the results that support your exercise schedule but don’t feel too comfortable about it if most of the week you are sitting at a desk.” 

For the rest of us — whether we are pediatricians, family practitioners, or internists — the message is to ease off our messaging on exercise and spend more energy getting our patients off their rear ends. It’s beginning to feel like we should be including accelerometers in our regular diagnostic and therapeutic weaponry. Sending home patients with a Holter cardiac monitor has become commonplace. We should be sending more folks home with accelerometers or asking the more affluent to share the data from their smart watches. “You’ve been bragging about your “steps. Show me your sitting time.”

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

The answer one gets often depends on how one crafts the question. For example, Jeffrey D. Johnson PhD, a professor of communications at Portland State University in Oregon has found that if patients are asked “Is there something else you would like to address today?” 80% had their unmet questions addressed. However, if the question was worded “Is there anything else ...?” Very few had their unmet concerns addressed.

I recently encountered two studies that provide another striking example of how differently structured questions aimed at same topic can result in dramatically different results. In this case both studies used one database, the UK Biobank cohort study which contains “de-identified genetic, lifestyle, and health information” collected from a half million adults in the UK. A subgroup of nearly 90,000 who had undergone a week long activity measurement using a wrist accelerometer was the focus of both groups of investigators who asked the same broad question “What is the relationship between physical activity and disease?”

 

The first study I found has already received some publicity in the lay press and dealt with those individuals who, for a variety of reasons, pack all of their exercise into just a few days, usually the weekend, aka weekend warriors. The investigators found that when compared with generally inactive individuals those who were able to achieve activity volumes that met current guidelines were at lower risk for more than 200 diseases, particularly those that were cardiac based. I guess that shouldn’t surprise us. The finding that has received most of the publicity to date in the lay press was that “Associations were similar whether the activity followed a weekend warrior pattern or was spread out evenly through the week.”

The second study, using the same database, found that those individuals who spent more than 10.6 hours per day sitting had 60% an increased risk of heart failure and cardiovascular related death. And, here’s the real news, that risk remained even in people who were otherwise physically active.

I suspect these two groups of investigators, both associated with Harvard-related institutions, knew of each other’s work and would agree that their findings are not incompatible. However, it is interesting that, when presented with the same database, one group chose to focus its attention on the exercise end of the spectrum while the other looked at the effect of inactivity. 

I have always tried to include a “healthy” amount of exercise in my day. However, more recently my professional interest has been drawn to the increasing number of studies I read that deal with the risks of inactivity and sedentarism. For example, just in the last 2 years I have written about a study in children that showed that sedentary time is responsible for 70% of the total increase in cholesterol as children advance into young adulthood. Another study in adults found that every 2-hour increase in sedentary behavior was associated with a 12% decrease in the patient’s likelihood of achieving healthy aging.

If I were asked to place relative values on these two studies, I would say that the study highlighting the risk of prolonged sitting is potentially far more relevant to the population at large, which is for the most part sedentary. Of course, while I have no data to support my contention, I see the weekend warrior population as a niche group.

So what are the take-home messages from these two studies? One is for the weekend warrior. “You can take some comfort in the results that support your exercise schedule but don’t feel too comfortable about it if most of the week you are sitting at a desk.” 

For the rest of us — whether we are pediatricians, family practitioners, or internists — the message is to ease off our messaging on exercise and spend more energy getting our patients off their rear ends. It’s beginning to feel like we should be including accelerometers in our regular diagnostic and therapeutic weaponry. Sending home patients with a Holter cardiac monitor has become commonplace. We should be sending more folks home with accelerometers or asking the more affluent to share the data from their smart watches. “You’ve been bragging about your “steps. Show me your sitting time.”

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

In a recent survey of 1259 mothers published in the journal Pediatrics, 28% reported they had fallen asleep while feeding their babies, and 83% of those mothers reported that the sleep was unplanned. Although the study sample was small, the investigators found that sociodemographic factors did not increase the odds that a mother would fall asleep while feeding.

These numbers are not surprising, but nonetheless they are concerning because co-sleeping is a known risk factor for sudden unexplained infant death (SUID). Every parent will tell you during the first 6 months of their adventure in parenting they didn’t get enough sleep. In fact some will tell you that sleep deprivation was their chronic state for the child’s first year. 

 

Falling asleep easily at times and places not intended for sleep is the primary symptom of sleep deprivation. SUID is the most tragic event associated with parental sleep deprivation, but it is certainly not the only one. Overtired parents are more likely to be involved in accidents and are more likely to make poor decisions, particularly those regarding how to respond to a crying or misbehaving child.

The investigators found that 24% of mothers who reported that their usual nighttime feeding location was a chair or sofa (14%). Not surprisingly, mothers who fed in chairs were less likely to fall asleep while feeding. Many of these mothers reported that they chose the chair because they thought they would be less likely to fall asleep and/or disturb other family members. One wonders how we should interpret these numbers in light of other research that has found it is “relatively less hazardous to fall asleep with an infant in the adult bed than on a chair or sofa.” Had these chair feeding mothers made the better choice under the circumstances? It would take a much larger and more granular study to answer that question.

Mothers who exclusively breastfed were more likely to fall asleep feeding than were those who partially breastfed or used formula. The investigators postulated that the infants of mothers who exclusively breastfed may have required more feedings because breast milk is more easily and quickly digested. I know this is a common explanation, but in my experience I have found that exclusively breastfed infants often use nursing as pacification and a sleep trigger and spend more time at the breast regardless of how quickly they emptied their stomachs.

This study also examined the effect of repeated educational interventions and support and found that mothers who received an intervention based on safe sleep practices were less likely to fall asleep while feeding than were the mothers who had received the intervention focused on exclusive breastfeeding value and barriers to its adoption.

Certainly, the problem of mothers falling asleep while feeding is one we should address more robustly than we have in the past. Education is one avenue, particularly when it includes the mother’s partner who can play an important role as standby lifeguard to make sure the mother doesn’t fall asleep. Obviously, this is easier said than done because when there is a new baby in the house sleep deprivation is usually a shared experience.

Although I believe that my family is on the verge of gifting me a smartwatch to protect me from my own misadventures, I don’t have any personal experience with these wonders of modern technology. However, I suspect with very little tweaking a wearable sensor could be easily programmed to detect when a mother is beginning to fall asleep while she is feeding her infant. A smartwatch would be an expensive intervention and is unlikely to filter down to economically challenged families. On the other hand, this paper has reinforced our suspicions that sleep-deprived infant feeding is a significant problem. A subsidized loaner program for those families that can’t afford a smartwatch is an option that should be considered. 

 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

In a recent survey of 1259 mothers published in the journal Pediatrics, 28% reported they had fallen asleep while feeding their babies, and 83% of those mothers reported that the sleep was unplanned. Although the study sample was small, the investigators found that sociodemographic factors did not increase the odds that a mother would fall asleep while feeding.

These numbers are not surprising, but nonetheless they are concerning because co-sleeping is a known risk factor for sudden unexplained infant death (SUID). Every parent will tell you during the first 6 months of their adventure in parenting they didn’t get enough sleep. In fact some will tell you that sleep deprivation was their chronic state for the child’s first year. 

 

Falling asleep easily at times and places not intended for sleep is the primary symptom of sleep deprivation. SUID is the most tragic event associated with parental sleep deprivation, but it is certainly not the only one. Overtired parents are more likely to be involved in accidents and are more likely to make poor decisions, particularly those regarding how to respond to a crying or misbehaving child.

The investigators found that 24% of mothers who reported that their usual nighttime feeding location was a chair or sofa (14%). Not surprisingly, mothers who fed in chairs were less likely to fall asleep while feeding. Many of these mothers reported that they chose the chair because they thought they would be less likely to fall asleep and/or disturb other family members. One wonders how we should interpret these numbers in light of other research that has found it is “relatively less hazardous to fall asleep with an infant in the adult bed than on a chair or sofa.” Had these chair feeding mothers made the better choice under the circumstances? It would take a much larger and more granular study to answer that question.

Mothers who exclusively breastfed were more likely to fall asleep feeding than were those who partially breastfed or used formula. The investigators postulated that the infants of mothers who exclusively breastfed may have required more feedings because breast milk is more easily and quickly digested. I know this is a common explanation, but in my experience I have found that exclusively breastfed infants often use nursing as pacification and a sleep trigger and spend more time at the breast regardless of how quickly they emptied their stomachs.

This study also examined the effect of repeated educational interventions and support and found that mothers who received an intervention based on safe sleep practices were less likely to fall asleep while feeding than were the mothers who had received the intervention focused on exclusive breastfeeding value and barriers to its adoption.

Certainly, the problem of mothers falling asleep while feeding is one we should address more robustly than we have in the past. Education is one avenue, particularly when it includes the mother’s partner who can play an important role as standby lifeguard to make sure the mother doesn’t fall asleep. Obviously, this is easier said than done because when there is a new baby in the house sleep deprivation is usually a shared experience.

Although I believe that my family is on the verge of gifting me a smartwatch to protect me from my own misadventures, I don’t have any personal experience with these wonders of modern technology. However, I suspect with very little tweaking a wearable sensor could be easily programmed to detect when a mother is beginning to fall asleep while she is feeding her infant. A smartwatch would be an expensive intervention and is unlikely to filter down to economically challenged families. On the other hand, this paper has reinforced our suspicions that sleep-deprived infant feeding is a significant problem. A subsidized loaner program for those families that can’t afford a smartwatch is an option that should be considered. 

 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

In a recent survey of 1259 mothers published in the journal Pediatrics, 28% reported they had fallen asleep while feeding their babies, and 83% of those mothers reported that the sleep was unplanned. Although the study sample was small, the investigators found that sociodemographic factors did not increase the odds that a mother would fall asleep while feeding.

These numbers are not surprising, but nonetheless they are concerning because co-sleeping is a known risk factor for sudden unexplained infant death (SUID). Every parent will tell you during the first 6 months of their adventure in parenting they didn’t get enough sleep. In fact some will tell you that sleep deprivation was their chronic state for the child’s first year. 

 

Falling asleep easily at times and places not intended for sleep is the primary symptom of sleep deprivation. SUID is the most tragic event associated with parental sleep deprivation, but it is certainly not the only one. Overtired parents are more likely to be involved in accidents and are more likely to make poor decisions, particularly those regarding how to respond to a crying or misbehaving child.

The investigators found that 24% of mothers who reported that their usual nighttime feeding location was a chair or sofa (14%). Not surprisingly, mothers who fed in chairs were less likely to fall asleep while feeding. Many of these mothers reported that they chose the chair because they thought they would be less likely to fall asleep and/or disturb other family members. One wonders how we should interpret these numbers in light of other research that has found it is “relatively less hazardous to fall asleep with an infant in the adult bed than on a chair or sofa.” Had these chair feeding mothers made the better choice under the circumstances? It would take a much larger and more granular study to answer that question.

Mothers who exclusively breastfed were more likely to fall asleep feeding than were those who partially breastfed or used formula. The investigators postulated that the infants of mothers who exclusively breastfed may have required more feedings because breast milk is more easily and quickly digested. I know this is a common explanation, but in my experience I have found that exclusively breastfed infants often use nursing as pacification and a sleep trigger and spend more time at the breast regardless of how quickly they emptied their stomachs.

This study also examined the effect of repeated educational interventions and support and found that mothers who received an intervention based on safe sleep practices were less likely to fall asleep while feeding than were the mothers who had received the intervention focused on exclusive breastfeeding value and barriers to its adoption.

Certainly, the problem of mothers falling asleep while feeding is one we should address more robustly than we have in the past. Education is one avenue, particularly when it includes the mother’s partner who can play an important role as standby lifeguard to make sure the mother doesn’t fall asleep. Obviously, this is easier said than done because when there is a new baby in the house sleep deprivation is usually a shared experience.

Although I believe that my family is on the verge of gifting me a smartwatch to protect me from my own misadventures, I don’t have any personal experience with these wonders of modern technology. However, I suspect with very little tweaking a wearable sensor could be easily programmed to detect when a mother is beginning to fall asleep while she is feeding her infant. A smartwatch would be an expensive intervention and is unlikely to filter down to economically challenged families. On the other hand, this paper has reinforced our suspicions that sleep-deprived infant feeding is a significant problem. A subsidized loaner program for those families that can’t afford a smartwatch is an option that should be considered. 

 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

TOPLINE:

Up to one in seven young adults with obesity and type 2 diabetes (T2D) have clinically significant hepatic fibrosis, signaling the crucial need for screening in this population to aid early detection and intervention.

METHODOLOGY:

• Researchers aimed to assess the prevalence of hepatic steatosis and clinically significant fibrosis (stage ≥ 2) in young adults without a history of metabolic dysfunction–associated steatotic liver disease (MASLD), hypothesizing that the rates would be comparable with those in older adults, especially in the presence of cardiometabolic risk factors.
• Overall, 1420 participants aged 21-79 years with or without T2D (63% or 37%, respectively) were included from outpatient clinics at the University of Florida, Gainesville, Florida, and divided into two age groups: < 45 years (n = 243) and ≥ 45 years (n = 1177).
• All the participants underwent assessment of liver stiffness via transient elastography, with magnetic resonance elastography (MRE) or liver biopsy recommended when indicated.
• Participants also underwent a medical history review, physical examination, and fasting blood tests to rule out secondary causes of liver disease.

TAKEAWAY:

• Overall, 52% of participants had hepatic steatosis, and 9.5% had clinically significant fibrosis.
• There were no significant differences in the frequencies of hepatic steatosis (50.2% vs 52.7%; P = .6) or clinically significant hepatic fibrosis (7.5% vs 9.9%; P = .2) observed between young and older adults.
• The presence of either T2D or obesity was linked to an increased prevalence of both hepatic steatosis and fibrosis in both the age groups (P < .01).
• In young and older adults, the presence of both T2D and obesity led to the highest rates of both hepatic steatosis and clinically significant fibrosis, with the latter rate being statistically similar between the groups (15.7% vs 17.3%; P = .2).
• The presence of T2D and obesity was the strongest risk factors for hepatic fibrosis in young adults (odds ratios, 4.33 and 1.16, respectively; P < .05 for both).

IN PRACTICE:

“The clinical implication is that young adults with obesity and T2D carry a high risk of future cirrhosis, possibly as high as older adults, and must be aggressively screened at the first visit and carefully followed,” the authors wrote.

SOURCE:

This study, led by Anu Sharma, University of Florida College of Medicine, Gainesville, was published online in Obesity.

LIMITATIONS:

The diagnosis of clinically significant hepatic fibrosis was confirmed via MRE and/or liver biopsy in only 30% of all participants. The study population included a slightly higher proportion of young adults with obesity, T2D, and other cardiometabolic risk factors than that in national averages, which may have limited its generalizability. Genetic variants associated with MASLD were not included in this study.

DISCLOSURES:

This study was funded partly by grants from the National Institutes of Health and Echosens. One author disclosed receiving research support and serving as a consultant for various pharmaceutical companies.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

Up to one in seven young adults with obesity and type 2 diabetes (T2D) have clinically significant hepatic fibrosis, signaling the crucial need for screening in this population to aid early detection and intervention.

METHODOLOGY:

• Researchers aimed to assess the prevalence of hepatic steatosis and clinically significant fibrosis (stage ≥ 2) in young adults without a history of metabolic dysfunction–associated steatotic liver disease (MASLD), hypothesizing that the rates would be comparable with those in older adults, especially in the presence of cardiometabolic risk factors.
• Overall, 1420 participants aged 21-79 years with or without T2D (63% or 37%, respectively) were included from outpatient clinics at the University of Florida, Gainesville, Florida, and divided into two age groups: < 45 years (n = 243) and ≥ 45 years (n = 1177).
• All the participants underwent assessment of liver stiffness via transient elastography, with magnetic resonance elastography (MRE) or liver biopsy recommended when indicated.
• Participants also underwent a medical history review, physical examination, and fasting blood tests to rule out secondary causes of liver disease.

TAKEAWAY:

• Overall, 52% of participants had hepatic steatosis, and 9.5% had clinically significant fibrosis.
• There were no significant differences in the frequencies of hepatic steatosis (50.2% vs 52.7%; P = .6) or clinically significant hepatic fibrosis (7.5% vs 9.9%; P = .2) observed between young and older adults.
• The presence of either T2D or obesity was linked to an increased prevalence of both hepatic steatosis and fibrosis in both the age groups (P < .01).
• In young and older adults, the presence of both T2D and obesity led to the highest rates of both hepatic steatosis and clinically significant fibrosis, with the latter rate being statistically similar between the groups (15.7% vs 17.3%; P = .2).
• The presence of T2D and obesity was the strongest risk factors for hepatic fibrosis in young adults (odds ratios, 4.33 and 1.16, respectively; P < .05 for both).

IN PRACTICE:

“The clinical implication is that young adults with obesity and T2D carry a high risk of future cirrhosis, possibly as high as older adults, and must be aggressively screened at the first visit and carefully followed,” the authors wrote.

SOURCE:

This study, led by Anu Sharma, University of Florida College of Medicine, Gainesville, was published online in Obesity.

LIMITATIONS:

The diagnosis of clinically significant hepatic fibrosis was confirmed via MRE and/or liver biopsy in only 30% of all participants. The study population included a slightly higher proportion of young adults with obesity, T2D, and other cardiometabolic risk factors than that in national averages, which may have limited its generalizability. Genetic variants associated with MASLD were not included in this study.

DISCLOSURES:

This study was funded partly by grants from the National Institutes of Health and Echosens. One author disclosed receiving research support and serving as a consultant for various pharmaceutical companies.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

Up to one in seven young adults with obesity and type 2 diabetes (T2D) have clinically significant hepatic fibrosis, signaling the crucial need for screening in this population to aid early detection and intervention.

METHODOLOGY:

• Researchers aimed to assess the prevalence of hepatic steatosis and clinically significant fibrosis (stage ≥ 2) in young adults without a history of metabolic dysfunction–associated steatotic liver disease (MASLD), hypothesizing that the rates would be comparable with those in older adults, especially in the presence of cardiometabolic risk factors.
• Overall, 1420 participants aged 21-79 years with or without T2D (63% or 37%, respectively) were included from outpatient clinics at the University of Florida, Gainesville, Florida, and divided into two age groups: < 45 years (n = 243) and ≥ 45 years (n = 1177).
• All the participants underwent assessment of liver stiffness via transient elastography, with magnetic resonance elastography (MRE) or liver biopsy recommended when indicated.
• Participants also underwent a medical history review, physical examination, and fasting blood tests to rule out secondary causes of liver disease.

TAKEAWAY:

• Overall, 52% of participants had hepatic steatosis, and 9.5% had clinically significant fibrosis.
• There were no significant differences in the frequencies of hepatic steatosis (50.2% vs 52.7%; P = .6) or clinically significant hepatic fibrosis (7.5% vs 9.9%; P = .2) observed between young and older adults.
• The presence of either T2D or obesity was linked to an increased prevalence of both hepatic steatosis and fibrosis in both the age groups (P < .01).
• In young and older adults, the presence of both T2D and obesity led to the highest rates of both hepatic steatosis and clinically significant fibrosis, with the latter rate being statistically similar between the groups (15.7% vs 17.3%; P = .2).
• The presence of T2D and obesity was the strongest risk factors for hepatic fibrosis in young adults (odds ratios, 4.33 and 1.16, respectively; P < .05 for both).

IN PRACTICE:

“The clinical implication is that young adults with obesity and T2D carry a high risk of future cirrhosis, possibly as high as older adults, and must be aggressively screened at the first visit and carefully followed,” the authors wrote.

SOURCE:

This study, led by Anu Sharma, University of Florida College of Medicine, Gainesville, was published online in Obesity.

LIMITATIONS:

The diagnosis of clinically significant hepatic fibrosis was confirmed via MRE and/or liver biopsy in only 30% of all participants. The study population included a slightly higher proportion of young adults with obesity, T2D, and other cardiometabolic risk factors than that in national averages, which may have limited its generalizability. Genetic variants associated with MASLD were not included in this study.

DISCLOSURES:

This study was funded partly by grants from the National Institutes of Health and Echosens. One author disclosed receiving research support and serving as a consultant for various pharmaceutical companies.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

If we’ve learned anything about obesity prevention it’s that if we wait too long the die is cast and our success rate is nil. The GLP-1 antagonists seem to be a workable solution for treating the adult and adolescent population, but I have been afraid that their success will divert too much of our attention away from prevention.

Fortunately, there still seems to be a few researchers committed to the age group in which obesity could be headed off before our only option is treatment. In one recent study, “Neighborhood Food Access in Early Life and Trajectories of Child Body Mass Index and Obesity,” researchers collected data from more than 28,000 children in 55 cohorts during the period from 1994 to 2023). The investigators found that residence in a low–food access, low-income neighborhoods during pregnancy and early childhood was associated with higher BMI “Z” scores, a higher risk of obesity, and severe obesity in childhood. The researchers defined low food access as living greater than 0.5 miles away from a grocery store in an urban setting or greater than 10 minutes away in a rural setting. I don’t think those associations should surprise us, but having some data from a large population may be valuable should we ever find the political will to undertake any steps toward prevention.

I found a Viewpoint article published 2 weeks earlier in the same journal, titled, “The Exposome as a Key to Understanding Pediatric Health Disparities.” I know what the “biome” is and have heard gastroenterologists expound on the power that billions of our little single-celled friends residing in our gut have on seemingly unrelated and spatially distant events in our body. But, “exposome” was a new word for me, although it turns out the concept is simple and one I had harbored since late childhood. 

 

The opening sentence of the article reads “One’s environment profoundly changes health outcomes throughout one’s lifespan.” That truism was obvious to my 7-year-old self as I observed my playmates who lived in a poorly kept house in the less desirable area two blocks away and didn’t eat breakfast and were sick more often than the rest of us more-fortunates.

The authors define the exposome as the “totality of an individual’s non-genetic exposures, including psychosocial experiences, structural social determinants, chemical pollution, and neighborhood infrastructure.” This seems to be a pretty complete description of the nurture side of the nature versus nurture conversation. 

I suspect that, like me, most of you through observation and intuition have included your own interpretation of the exposome in your professional activities. However, the authors feel we could be more robust in our efforts and claim that “current pediatric practice largely neglects to characterize health disparities in terms of salient environmental practices.” They go on to call for incorporation of an “exposome lens in pediatric research and healthcare delivery.”

I’m not sure this is a valid criticism. There is certainly more that could be done when it comes to research that examines the effect of environmental stressors. And, I suspect the authors would view this recent paper on the association between neighborhood food access as a step in the right direction. However, when it comes to healthcare delivery, at least at the level where the stethoscope meets the chest, I think, or at least hope, the authors are underestimating the observational skills and sensitivity of primary care providers.

We were all taught to take an appropriate medical history when evaluating a patient. And, through our formal education, our personal observations and through exposure to papers like this one on food access we must be aware of the effect of environmental stressors on our patients’ health. Is there more we could learn about those kind of associations? Certainly. This is where a more broadly focused exposome lens could be most effective. 

The authors of the article observed: “The effect of the exposome is not uniform for all individuals but rather intersects across identities precipitating unique outcomes.” The practical reality is that to generate statistically significant data research must look at identities. This doesn’t mean that large population studies are without value. However, it does obligate investigators to include that caveat about the uniqueness of the individual in their conclusions. And, it is our duty as providers to keep this reality in mind as we interpret studies we read in the context of each individual patient. 

When it comes to healthcare delivery at the structural level, I am concerned that we are moving in a direction that is making it more difficult for the provider to become familiar with the patient’s exposome. I am talking about an over-reliance on the team care delivery model that too often results in the “We never/seldom see the same provider” patient complaint.

I don’t care how slick and user-friendly a practice’s EHR system is; the best way to learn about a patient’s exposome is by repeated exposure (pun unintended) to the same provider. This isn’t always possible, and a well-crafted and conscientiously managed EHR can fill in some of the gaps. But, it is a distant second best. 

Awareness of the importance of the exposome is only the starting point. Finding the political will to make the changes necessary to improve our patients’ outcomes is the bigger challenge. Grocery stores well-stocked with healthy foods don’t just pop up where we want them because we think they may hold answer to preventing pediatric obesity.

 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

If we’ve learned anything about obesity prevention it’s that if we wait too long the die is cast and our success rate is nil. The GLP-1 antagonists seem to be a workable solution for treating the adult and adolescent population, but I have been afraid that their success will divert too much of our attention away from prevention.

Fortunately, there still seems to be a few researchers committed to the age group in which obesity could be headed off before our only option is treatment. In one recent study, “Neighborhood Food Access in Early Life and Trajectories of Child Body Mass Index and Obesity,” researchers collected data from more than 28,000 children in 55 cohorts during the period from 1994 to 2023). The investigators found that residence in a low–food access, low-income neighborhoods during pregnancy and early childhood was associated with higher BMI “Z” scores, a higher risk of obesity, and severe obesity in childhood. The researchers defined low food access as living greater than 0.5 miles away from a grocery store in an urban setting or greater than 10 minutes away in a rural setting. I don’t think those associations should surprise us, but having some data from a large population may be valuable should we ever find the political will to undertake any steps toward prevention.

I found a Viewpoint article published 2 weeks earlier in the same journal, titled, “The Exposome as a Key to Understanding Pediatric Health Disparities.” I know what the “biome” is and have heard gastroenterologists expound on the power that billions of our little single-celled friends residing in our gut have on seemingly unrelated and spatially distant events in our body. But, “exposome” was a new word for me, although it turns out the concept is simple and one I had harbored since late childhood. 

 

The opening sentence of the article reads “One’s environment profoundly changes health outcomes throughout one’s lifespan.” That truism was obvious to my 7-year-old self as I observed my playmates who lived in a poorly kept house in the less desirable area two blocks away and didn’t eat breakfast and were sick more often than the rest of us more-fortunates.

The authors define the exposome as the “totality of an individual’s non-genetic exposures, including psychosocial experiences, structural social determinants, chemical pollution, and neighborhood infrastructure.” This seems to be a pretty complete description of the nurture side of the nature versus nurture conversation. 

I suspect that, like me, most of you through observation and intuition have included your own interpretation of the exposome in your professional activities. However, the authors feel we could be more robust in our efforts and claim that “current pediatric practice largely neglects to characterize health disparities in terms of salient environmental practices.” They go on to call for incorporation of an “exposome lens in pediatric research and healthcare delivery.”

I’m not sure this is a valid criticism. There is certainly more that could be done when it comes to research that examines the effect of environmental stressors. And, I suspect the authors would view this recent paper on the association between neighborhood food access as a step in the right direction. However, when it comes to healthcare delivery, at least at the level where the stethoscope meets the chest, I think, or at least hope, the authors are underestimating the observational skills and sensitivity of primary care providers.

We were all taught to take an appropriate medical history when evaluating a patient. And, through our formal education, our personal observations and through exposure to papers like this one on food access we must be aware of the effect of environmental stressors on our patients’ health. Is there more we could learn about those kind of associations? Certainly. This is where a more broadly focused exposome lens could be most effective. 

The authors of the article observed: “The effect of the exposome is not uniform for all individuals but rather intersects across identities precipitating unique outcomes.” The practical reality is that to generate statistically significant data research must look at identities. This doesn’t mean that large population studies are without value. However, it does obligate investigators to include that caveat about the uniqueness of the individual in their conclusions. And, it is our duty as providers to keep this reality in mind as we interpret studies we read in the context of each individual patient. 

When it comes to healthcare delivery at the structural level, I am concerned that we are moving in a direction that is making it more difficult for the provider to become familiar with the patient’s exposome. I am talking about an over-reliance on the team care delivery model that too often results in the “We never/seldom see the same provider” patient complaint.

I don’t care how slick and user-friendly a practice’s EHR system is; the best way to learn about a patient’s exposome is by repeated exposure (pun unintended) to the same provider. This isn’t always possible, and a well-crafted and conscientiously managed EHR can fill in some of the gaps. But, it is a distant second best. 

Awareness of the importance of the exposome is only the starting point. Finding the political will to make the changes necessary to improve our patients’ outcomes is the bigger challenge. Grocery stores well-stocked with healthy foods don’t just pop up where we want them because we think they may hold answer to preventing pediatric obesity.

 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

If we’ve learned anything about obesity prevention it’s that if we wait too long the die is cast and our success rate is nil. The GLP-1 antagonists seem to be a workable solution for treating the adult and adolescent population, but I have been afraid that their success will divert too much of our attention away from prevention.

Fortunately, there still seems to be a few researchers committed to the age group in which obesity could be headed off before our only option is treatment. In one recent study, “Neighborhood Food Access in Early Life and Trajectories of Child Body Mass Index and Obesity,” researchers collected data from more than 28,000 children in 55 cohorts during the period from 1994 to 2023). The investigators found that residence in a low–food access, low-income neighborhoods during pregnancy and early childhood was associated with higher BMI “Z” scores, a higher risk of obesity, and severe obesity in childhood. The researchers defined low food access as living greater than 0.5 miles away from a grocery store in an urban setting or greater than 10 minutes away in a rural setting. I don’t think those associations should surprise us, but having some data from a large population may be valuable should we ever find the political will to undertake any steps toward prevention.

I found a Viewpoint article published 2 weeks earlier in the same journal, titled, “The Exposome as a Key to Understanding Pediatric Health Disparities.” I know what the “biome” is and have heard gastroenterologists expound on the power that billions of our little single-celled friends residing in our gut have on seemingly unrelated and spatially distant events in our body. But, “exposome” was a new word for me, although it turns out the concept is simple and one I had harbored since late childhood. 

 

The opening sentence of the article reads “One’s environment profoundly changes health outcomes throughout one’s lifespan.” That truism was obvious to my 7-year-old self as I observed my playmates who lived in a poorly kept house in the less desirable area two blocks away and didn’t eat breakfast and were sick more often than the rest of us more-fortunates.

The authors define the exposome as the “totality of an individual’s non-genetic exposures, including psychosocial experiences, structural social determinants, chemical pollution, and neighborhood infrastructure.” This seems to be a pretty complete description of the nurture side of the nature versus nurture conversation. 

I suspect that, like me, most of you through observation and intuition have included your own interpretation of the exposome in your professional activities. However, the authors feel we could be more robust in our efforts and claim that “current pediatric practice largely neglects to characterize health disparities in terms of salient environmental practices.” They go on to call for incorporation of an “exposome lens in pediatric research and healthcare delivery.”

I’m not sure this is a valid criticism. There is certainly more that could be done when it comes to research that examines the effect of environmental stressors. And, I suspect the authors would view this recent paper on the association between neighborhood food access as a step in the right direction. However, when it comes to healthcare delivery, at least at the level where the stethoscope meets the chest, I think, or at least hope, the authors are underestimating the observational skills and sensitivity of primary care providers.

We were all taught to take an appropriate medical history when evaluating a patient. And, through our formal education, our personal observations and through exposure to papers like this one on food access we must be aware of the effect of environmental stressors on our patients’ health. Is there more we could learn about those kind of associations? Certainly. This is where a more broadly focused exposome lens could be most effective. 

The authors of the article observed: “The effect of the exposome is not uniform for all individuals but rather intersects across identities precipitating unique outcomes.” The practical reality is that to generate statistically significant data research must look at identities. This doesn’t mean that large population studies are without value. However, it does obligate investigators to include that caveat about the uniqueness of the individual in their conclusions. And, it is our duty as providers to keep this reality in mind as we interpret studies we read in the context of each individual patient. 

When it comes to healthcare delivery at the structural level, I am concerned that we are moving in a direction that is making it more difficult for the provider to become familiar with the patient’s exposome. I am talking about an over-reliance on the team care delivery model that too often results in the “We never/seldom see the same provider” patient complaint.

I don’t care how slick and user-friendly a practice’s EHR system is; the best way to learn about a patient’s exposome is by repeated exposure (pun unintended) to the same provider. This isn’t always possible, and a well-crafted and conscientiously managed EHR can fill in some of the gaps. But, it is a distant second best. 

Awareness of the importance of the exposome is only the starting point. Finding the political will to make the changes necessary to improve our patients’ outcomes is the bigger challenge. Grocery stores well-stocked with healthy foods don’t just pop up where we want them because we think they may hold answer to preventing pediatric obesity.

 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

The United States Preventive Services Task Force (USPSTF) has issued an updated draft recommendation statement advising early screening for syphilis in all pregnant persons with no signs or symptoms of syphilis, regardless of risk. Those with abnormal screening results should receive “timely, equitable, and evidence-based evaluation and treatment for syphilis,” it advises.

Reaffirming the task force’s 2018 statement, in which an evidence review found the benefits of screening substantially outweighed the harms, the current draft is based on no substantial new data. It is open for public input until December 23.

“Congenital syphilis infection is still an important health problem, and rates are not decreasing as they should,” said USPSTF panel member Carlos R. Jaén, MD, PhD, MS, Dr. and Mrs. James L. Holly Distinguished Chair in the Department of Family and Community Medicine at the Joe R. and Teresa Lozano Long School of Medicine at the University of Texas Health Science Center at San Antonio. “Cases are 10 times higher today than they were a decade ago, despite the harmful consequences of syphilis infection in mother and baby and despite it being a preventable and easily treated condition.”

The statement notes that untreated syphilis infection in mothers is associated with miscarriage, premature birth, low birth weight, stillbirth, and neonatal death. Syphilis infection is linked to significant abnormalities in infants such as deformed bones, anemia, enlarged liver and spleen, jaundice, meningitis, and brain and nerve problems resulting in permanent vision or hearing loss.

The USPSTF statement aligns with the recommendations of other healthcare organizations, including the American College of Obstetricians and Gynecologists (ACOG), which issued a clinical practice advisory on prenatal syphilis screening in April 2024.

This advisory recommends obstetric care providers screen all pregnant individuals serologically for syphilis at the first prenatal care visit, with universal rescreening during the third trimester and at birth rather than targeted risk-based testing.

The advisory notes that two in five infants with congenital syphilis were born to persons who received no prenatal care. It urges making any healthcare encounter during pregnancy — in emergency departments, jails, syringe service programs, and maternal and child health clinics — an opportunity to screen for syphilis.

So far, there is no official guidance on preconception screening for persons planning a pregnancy, according to Allison Bryant Mantha, MD, MPH, a maternal-fetal medicine specialist at Mass General Brigham health system and an associate professor at Harvard School of Medicine in Boston, Massachusetts, who coauthored the ACOG advisory.

But Lynn M. Yee, MD, MPH, an associate professor of maternal-fetal medicine at Northwestern University Feinberg School of Medicine and director of the Northwestern Medicine Women’s Infectious Disease Program in Chicago, Illinois, said syphilis testing could easily be part of a prepregnancy “bucket” of health checkup items along with other sexually transmitted infections and blood pressure.

 

By the Numbers

In 2022, there were 3761 cases of congenital syphilis in the United States, including 231 stillbirths and 51 infant deaths — the highest number reported in more than 30 years and more than 10 times that reported in 2012.

At play may be social, economic, and immigration status factors creating barriers to prenatal care as well as declines in prevention infrastructure and resources.

Although most syphilis cases occur in men, the increase in incidence rate in women was two to four times higher than that of men from 2017 to 2021.

 

Why Such Persistently High Rates?

Despite a widely available test and cost-effective penicillin treatment covered by most insurance, congenital syphilis remains a challenge. According to Bryant, many mothers are still presenting for care and testing late in pregnancy. “Differential access to care is just one of many reasons,” she said.

Stigma and bias may also play a part, according to Yee. “Some clinicians may think their patient population is not the kind to be at risk and doesn’t need to be screened,” she said. Furthermore, screening is not a one-off test but a two-step process, and serology results can be hard to understand and easy to misinterpret.

In addition, some situations may promote ongoing disease, according to Yee. “Reinfection can occur after treatment if a patient keeps returning to a partner who refuses treatment,” Yee said.

On an optimistic note, however, the Centers for Disease Control and Prevention (CDC) reports that in some areas increases in newborn syphilis cases appear to be slowing — with a 3% increase in 2022 than with a 30% or higher annual increases in previous years. In 2020-2021, for example, congenital cases rose by 32% and resulted in 220 stillbirths and infant deaths.

 

Going Forward

The USPSTF statement identifies knowledge gaps. These include studies to evaluate the benefits and harms of repeat screening later in pregnancy and to evaluate the benefits and harms of such strategies as rapid point-of-care tests. The USPSTF also called for research on disparities in syphilis incidence and screening rates to reduce these disparities in populations.

Within these vulnerable groups, the CDC noted that babies born to Black, Hispanic, or Native American/Alaska Native mothers in 2021 were as much as eight times more likely to have congenital syphilis than those born to their White counterparts.

Jaén, Bryant, and Yee had no competing interests relevant to their comments.

A version of this article appeared on Medscape.com.

The United States Preventive Services Task Force (USPSTF) has issued an updated draft recommendation statement advising early screening for syphilis in all pregnant persons with no signs or symptoms of syphilis, regardless of risk. Those with abnormal screening results should receive “timely, equitable, and evidence-based evaluation and treatment for syphilis,” it advises.

Reaffirming the task force’s 2018 statement, in which an evidence review found the benefits of screening substantially outweighed the harms, the current draft is based on no substantial new data. It is open for public input until December 23.

“Congenital syphilis infection is still an important health problem, and rates are not decreasing as they should,” said USPSTF panel member Carlos R. Jaén, MD, PhD, MS, Dr. and Mrs. James L. Holly Distinguished Chair in the Department of Family and Community Medicine at the Joe R. and Teresa Lozano Long School of Medicine at the University of Texas Health Science Center at San Antonio. “Cases are 10 times higher today than they were a decade ago, despite the harmful consequences of syphilis infection in mother and baby and despite it being a preventable and easily treated condition.”

The statement notes that untreated syphilis infection in mothers is associated with miscarriage, premature birth, low birth weight, stillbirth, and neonatal death. Syphilis infection is linked to significant abnormalities in infants such as deformed bones, anemia, enlarged liver and spleen, jaundice, meningitis, and brain and nerve problems resulting in permanent vision or hearing loss.

The USPSTF statement aligns with the recommendations of other healthcare organizations, including the American College of Obstetricians and Gynecologists (ACOG), which issued a clinical practice advisory on prenatal syphilis screening in April 2024.

This advisory recommends obstetric care providers screen all pregnant individuals serologically for syphilis at the first prenatal care visit, with universal rescreening during the third trimester and at birth rather than targeted risk-based testing.

The advisory notes that two in five infants with congenital syphilis were born to persons who received no prenatal care. It urges making any healthcare encounter during pregnancy — in emergency departments, jails, syringe service programs, and maternal and child health clinics — an opportunity to screen for syphilis.

So far, there is no official guidance on preconception screening for persons planning a pregnancy, according to Allison Bryant Mantha, MD, MPH, a maternal-fetal medicine specialist at Mass General Brigham health system and an associate professor at Harvard School of Medicine in Boston, Massachusetts, who coauthored the ACOG advisory.

But Lynn M. Yee, MD, MPH, an associate professor of maternal-fetal medicine at Northwestern University Feinberg School of Medicine and director of the Northwestern Medicine Women’s Infectious Disease Program in Chicago, Illinois, said syphilis testing could easily be part of a prepregnancy “bucket” of health checkup items along with other sexually transmitted infections and blood pressure.

 

By the Numbers

In 2022, there were 3761 cases of congenital syphilis in the United States, including 231 stillbirths and 51 infant deaths — the highest number reported in more than 30 years and more than 10 times that reported in 2012.

At play may be social, economic, and immigration status factors creating barriers to prenatal care as well as declines in prevention infrastructure and resources.

Although most syphilis cases occur in men, the increase in incidence rate in women was two to four times higher than that of men from 2017 to 2021.

 

Why Such Persistently High Rates?

Despite a widely available test and cost-effective penicillin treatment covered by most insurance, congenital syphilis remains a challenge. According to Bryant, many mothers are still presenting for care and testing late in pregnancy. “Differential access to care is just one of many reasons,” she said.

Stigma and bias may also play a part, according to Yee. “Some clinicians may think their patient population is not the kind to be at risk and doesn’t need to be screened,” she said. Furthermore, screening is not a one-off test but a two-step process, and serology results can be hard to understand and easy to misinterpret.

In addition, some situations may promote ongoing disease, according to Yee. “Reinfection can occur after treatment if a patient keeps returning to a partner who refuses treatment,” Yee said.

On an optimistic note, however, the Centers for Disease Control and Prevention (CDC) reports that in some areas increases in newborn syphilis cases appear to be slowing — with a 3% increase in 2022 than with a 30% or higher annual increases in previous years. In 2020-2021, for example, congenital cases rose by 32% and resulted in 220 stillbirths and infant deaths.

 

Going Forward

The USPSTF statement identifies knowledge gaps. These include studies to evaluate the benefits and harms of repeat screening later in pregnancy and to evaluate the benefits and harms of such strategies as rapid point-of-care tests. The USPSTF also called for research on disparities in syphilis incidence and screening rates to reduce these disparities in populations.

Within these vulnerable groups, the CDC noted that babies born to Black, Hispanic, or Native American/Alaska Native mothers in 2021 were as much as eight times more likely to have congenital syphilis than those born to their White counterparts.

Jaén, Bryant, and Yee had no competing interests relevant to their comments.

A version of this article appeared on Medscape.com.

The United States Preventive Services Task Force (USPSTF) has issued an updated draft recommendation statement advising early screening for syphilis in all pregnant persons with no signs or symptoms of syphilis, regardless of risk. Those with abnormal screening results should receive “timely, equitable, and evidence-based evaluation and treatment for syphilis,” it advises.

Reaffirming the task force’s 2018 statement, in which an evidence review found the benefits of screening substantially outweighed the harms, the current draft is based on no substantial new data. It is open for public input until December 23.

“Congenital syphilis infection is still an important health problem, and rates are not decreasing as they should,” said USPSTF panel member Carlos R. Jaén, MD, PhD, MS, Dr. and Mrs. James L. Holly Distinguished Chair in the Department of Family and Community Medicine at the Joe R. and Teresa Lozano Long School of Medicine at the University of Texas Health Science Center at San Antonio. “Cases are 10 times higher today than they were a decade ago, despite the harmful consequences of syphilis infection in mother and baby and despite it being a preventable and easily treated condition.”

The statement notes that untreated syphilis infection in mothers is associated with miscarriage, premature birth, low birth weight, stillbirth, and neonatal death. Syphilis infection is linked to significant abnormalities in infants such as deformed bones, anemia, enlarged liver and spleen, jaundice, meningitis, and brain and nerve problems resulting in permanent vision or hearing loss.

The USPSTF statement aligns with the recommendations of other healthcare organizations, including the American College of Obstetricians and Gynecologists (ACOG), which issued a clinical practice advisory on prenatal syphilis screening in April 2024.

This advisory recommends obstetric care providers screen all pregnant individuals serologically for syphilis at the first prenatal care visit, with universal rescreening during the third trimester and at birth rather than targeted risk-based testing.

The advisory notes that two in five infants with congenital syphilis were born to persons who received no prenatal care. It urges making any healthcare encounter during pregnancy — in emergency departments, jails, syringe service programs, and maternal and child health clinics — an opportunity to screen for syphilis.

So far, there is no official guidance on preconception screening for persons planning a pregnancy, according to Allison Bryant Mantha, MD, MPH, a maternal-fetal medicine specialist at Mass General Brigham health system and an associate professor at Harvard School of Medicine in Boston, Massachusetts, who coauthored the ACOG advisory.

But Lynn M. Yee, MD, MPH, an associate professor of maternal-fetal medicine at Northwestern University Feinberg School of Medicine and director of the Northwestern Medicine Women’s Infectious Disease Program in Chicago, Illinois, said syphilis testing could easily be part of a prepregnancy “bucket” of health checkup items along with other sexually transmitted infections and blood pressure.

 

By the Numbers

In 2022, there were 3761 cases of congenital syphilis in the United States, including 231 stillbirths and 51 infant deaths — the highest number reported in more than 30 years and more than 10 times that reported in 2012.

At play may be social, economic, and immigration status factors creating barriers to prenatal care as well as declines in prevention infrastructure and resources.

Although most syphilis cases occur in men, the increase in incidence rate in women was two to four times higher than that of men from 2017 to 2021.

 

Why Such Persistently High Rates?

Despite a widely available test and cost-effective penicillin treatment covered by most insurance, congenital syphilis remains a challenge. According to Bryant, many mothers are still presenting for care and testing late in pregnancy. “Differential access to care is just one of many reasons,” she said.

Stigma and bias may also play a part, according to Yee. “Some clinicians may think their patient population is not the kind to be at risk and doesn’t need to be screened,” she said. Furthermore, screening is not a one-off test but a two-step process, and serology results can be hard to understand and easy to misinterpret.

In addition, some situations may promote ongoing disease, according to Yee. “Reinfection can occur after treatment if a patient keeps returning to a partner who refuses treatment,” Yee said.

On an optimistic note, however, the Centers for Disease Control and Prevention (CDC) reports that in some areas increases in newborn syphilis cases appear to be slowing — with a 3% increase in 2022 than with a 30% or higher annual increases in previous years. In 2020-2021, for example, congenital cases rose by 32% and resulted in 220 stillbirths and infant deaths.

 

Going Forward

The USPSTF statement identifies knowledge gaps. These include studies to evaluate the benefits and harms of repeat screening later in pregnancy and to evaluate the benefits and harms of such strategies as rapid point-of-care tests. The USPSTF also called for research on disparities in syphilis incidence and screening rates to reduce these disparities in populations.

Within these vulnerable groups, the CDC noted that babies born to Black, Hispanic, or Native American/Alaska Native mothers in 2021 were as much as eight times more likely to have congenital syphilis than those born to their White counterparts.

Jaén, Bryant, and Yee had no competing interests relevant to their comments.

A version of this article appeared on Medscape.com.