Opinion Editorial
6. New Pediatric Labeling Information Database. US Food and Drug Administration website. http://www.accessdata.fda.gov/scripts/sda /sdNavigation.cfm?sd=labelingdatabase. Accessed November 6, 2013. 7. Ward RM, Kern SE. Clinical trials in neonates: a therapeutic imperative. Clin Pharmacol Ther. 2009;86(6):585-587. 8. Laughon MM, Avant D, Tripathi N, et al. Drug labeling and exposure in neonates [published
online December 9, 2013]. JAMA Pediatr. doi:10.1001/jamapediatrics.2013.4208.
premature babies (EUNO): a randomised controlled trial. Lancet. 2010;376(9738):346-354.
9. Ballard RA, Truog WE, Cnaan A, et al; NO CLD Study Group. Inhaled nitric oxide in preterm infants undergoing mechanical ventilation. N Engl J Med. 2006;355(4):343-353.
11. Pediatric studies of sodium nitroprusside conducted in accordance with section 409I of the Public Health Service Act; Establishment of Public Docket. Fed Regist. 2012;77(192):60441-60442. http://docs.regulations.justia.com/entries/2012-10 -03/2012-24213.pdf. Accessed November 6, 2013.
10. Mercier JC, Hummler H, Durrmeyer X, et al; EUNO Study Group. Inhaled nitric oxide for prevention of bronchopulmonary dysplasia in
The Beginning of the End of Measles and Rubella Mark Grabowsky, MD, MPH
Measles was first imported into the New World in the early 16th century by European colonists, often with devastating effects on native populations. Rubella importation followed and led to congenital rubella syndrome. It is estimated that during the following 5 centuRelated article page 148 ries, more than 200 million people globally died of measles. Disease incidence fell rapidly after the availability of vaccines in the United States for measles in 1963 and rubella in 1969, and after the availability of a combined measles-rubella vaccine in 1971. As vaccination expanded into other countries of the Americas, the Pan American Health Organization established a goal to eliminate measles from the Western hemisphere by 2002 and rubella by 2010. By 2004, transmission had been interrupted in the United States. However, there has been concern that pockets of transmission persisted or that transmission could be reestablished if immunization coverage levels declined. In this issue of the journal, Papania and colleagues1 report that an expert panel convened by the Centers for Disease Control and Prevention has determined that the elimination of endemic measles, rubella, and congenital rubella syndrome has been sustained for a decade. Along with certifications from other countries in the Americas, the entire Western hemisphere will be certified free of indigenous transmission. The elimination of measles and rubella from the Western hemisphere is a triumph of public health with several important implications. First, imported cases of measles and rubella will still likely occur as long as there remain endemic areas in the world. That these imported cases do not result in sustained transmission is confirmation that the level of population immunity is high enough for elimination. Prior to 1990, Mexico was the leading source of measles importations into the United States, but this year, half of all importations into the United States were from Europe.2 Since 2008, there has been a resurgence of measles cases in Western European countries. The majority of these outbreaks have been in unimmunized populations in countries where national immunization programs are being challenged by a combination of public and political complacency regarding the value of immunization and by the rising influence of antivaccination groups. After 500 108
years, we have now returned to a situation where the Americas are free from indigenous measles and rubella with Europe once again a source of importations. A second implication of the elimination of measles and rubella in the Western hemisphere is that it is a vindication of US vaccination strategy. Over the years, the United States experienced several false starts for measles and rubella elimination, with multiple missed target dates, but systematically incorporated the lessons learned from each failure into subsequent efforts.3 The essential elements of the final successful strategy were that (1) coverage with a first dose of measles-mumps-rubella (MMR) vaccine must be early, high, and sustained (in the United States, MMR vaccination rates among children younger than 2 years of age have been more than 90% for a decade); (2) each person must receive 2 doses of MMR vaccine (94.8% of children entering kindergarten have received 2 doses of MMR vaccine4); and (3) disease surveillance must include laboratory confirmation of suspected cases (there is a robust surveillance system for measles and genetic analysis of each virus to identify imported cases and their geographic source). It is encouraging that the European region has now endorsed these essential strategies, emphasizing routine vaccination and disease surveillance.5 The greatest threat to the US vaccination program may now come from parents’ hesitancy to vaccinate their children.6 Although this so-called vaccine hesitancy has not become as widespread in the United States as it appears to have become in Europe, it is increasing. Many measles outbreaks can be traced to people refusing to be vaccinated; a recent large measles outbreak was attributable to a church advocating the refusal of measles vaccination.7 Even greater risk may come from parents who delay vaccinations rather than refusing them outright because a delayed vaccination may add more personyears of susceptibility than that due to refusing vaccination. The single most important factor influencing decision making on childhood vaccination is the clear recommendation of a physician—clinicians must recognize their responsibility in supporting early vaccination. To address this issue, the National Vaccine Advisory Committee has convened a working group on vaccine hesitancy and has made some recommendations on how best to respond to it.
JAMA Pediatrics February 2014 Volume 168, Number 2
Copyright 2014 American Medical Association. All rights reserved.
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Editorial Opinion
Although the effect of expanded measles immunization in the United States has been a substantial decrease in morbidity, a notable effect in developing countries has been a substantial decrease in mortality. The aim of Millennium Development Goal 4 is to reduce the overall number of deaths among children by two-thirds by 2015, compared with the level in 1990. There are now 550 000 fewer annual deaths from measles today than there were a decade ago. Fully one-fourth of all mortality reduction toward Millennium Development Goal 4 has been due to measles control.8 Over 30 African countries now have more than 80% measles vaccination coverage resulting in a 91% decline in measles mortality.9 The success of global measles and rubella control is largely due to an innovative partnership, the Measles-Rubella Initiative, which was started in 2001 and has since supported delivering more than 1 billion doses of vaccine. Special recognition is due to the American Red Cross, which convened and hosts the initiative, and its partners, the United Nations Foundation, the Centers for Disease ARTICLE INFORMATION Author Affiliation: Office of the Secretary General's Special Envoy for Financing the Health Millennium Development Goals and for Malaria, New York, New York. Corresponding Author: Mark Grabowsky, MD, MPH, Office of the Secretary General's Special Envoy for Financing the Health Millennium Development Goals and for Malaria, 650 Madison Ave, 22nd Floor, New York, NY 10022 (MGrabowsky @mdghealthenvoy.org). Published Online: December 5, 2013. doi:10.1001/jamapediatrics.2013.4603. Conflict of Interest Disclosures: None reported. REFERENCES 1. Papania MJ, Wallace GS, Rota PA, et al. Elimination of endemic measles, rubella, and congenital rubella syndrome from the Western hemisphere: the US experience [published online December 5, 2013]. JAMA Pediatr. doi:10.1001/jamapediatrics.2013.4342.
Control and Prevention, the United Nations Children’s Fund, and the World Health Organization. The ending of the measles and rubella pandemic in the Western hemisphere is a stepping stone to global eradication. There is a consensus that the global eradication of measles will proceed if there is progress toward these regional goals.10 Has such progress been made? With close to 20 million people, São Paolo in Brazil may be the largest city in the world. With an estimated population of 4 million people, Mexico City’s NezaChalco-Itza is considered to be the largest slum on the planet. New York City is one of the largest and most visited cities in the world. Disease transmission has such an advantage in these cities that it would seem implausible to control any infectious diseases, much less eliminate 2 of the most infectious ones. And yet, even in these settings, measles and rubella have been eliminated for a decade. The world need look no further for proof that global eradication of measles and rubella can be successful.
2. Centers for Disease Control and Prevention (CDC). Measles—United States, January 1–August 24, 2013. MMWR Morb Mortal Wkly Rep. 2013;62(36):741-743. 3. Hinman AR, Orenstein WA, Papania MJ. Evolution of measles elimination strategies in the United States. J Infect Dis. 2004;189(suppl 1):S17-S22.
immunization, and the risks of vaccine-preventable diseases. N Engl J Med. 2009;360(19):1981-1988. 7. Texas megachurch of center of measles outbreak [transcript]. Weekend Edition Sunday. National Public Radio. September 1, 2013. http://www.npr .org/2013/09/01/217746942/texas-megachurch -at-center-of-measles-outbreak. Accessed October 16, 2013.
4. Vaccines and immunizations: statistics and surveillance. Coverage with individual vaccines from the inception of NIS, 1994 through 2012. Centers for Disease Control and Prevention website. http://www.cdc.gov/vaccines/stats-surv /nis/figures/2012_map.htm. Accessed October 16, 2013.
8. Strebel PM, Cochi SL, Hoekstra E, et al. A world without measles. J Infect Dis. 2011;204(suppl 1):S1-S3.
5. World Health Organization. Measles and rubella elimination 2015: package for accelerated action: 2013-2015. http://www.euro.who.int/__data/assets /pdf_file/0020/215480/PACKAGE-FOR -ACCELERATED-ACTION-20132015.pdf. Accessed October 13, 2013.
10. World Health Organization. Global eradication of measles: report by the Secretariat. http://apps.who.int/gb/ebwha/pdf_files/WHA63 /A63_18-en.pdf. Published March 25, 2010. Accessed November 19, 2013.
9. Centers for Disease Control and Prevention (CDC). Progress in global measles control and mortality reduction, 2000-2006. MMWR Morb Mortal Wkly Rep. 2007;56(47):1237-1241.
6. Omer SB, Salmon DA, Orenstein WA, deHart MP, Halsey N. Vaccine refusal, mandatory
To Eat or Not to Eat What Foods Are Safe to Consume During Pregnancy? Ruchi Gupta, MD, MPH
Mothers-to-be often seek advice from physicians on what is safe to eat during pregnancy in order to give their child the best chance of being healthy. Historically, understanding the relationship between a woman’s diet during pregnancy and Related article page 156 neonatal outcomes has been critical to avoiding negative sequelae. Two well-known examples include the following: (1) adequate dietary folic acid intake to prevent neural tube defects1; and (2) avoidance of soft unpasteurized cheeses to pre-
vent Listeria infections, which can result in fetal death or other long-term consequences.2,3 With the recent increase in childhood food allergies,4 it is no surprise that women are seeking added guidance on whether diet during pregnancy can influence their child’s risk of developing food allergy. Yet, guidelines, experts, and the science itself continue to change at a rate that leaves women confused. For example, recommendations regarding the ingestion of potentially allergenic foods during pregnancy have flipflopped for more than a decade. Although guidelines in 2000
jamapediatrics.com
JAMA Pediatrics February 2014 Volume 168, Number 2
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a J H Quillen College User on 06/15/2015
109
6. New Pediatric Labeling Information Database. US Food and Drug Administration website. http://www.accessdata.fda.gov/scripts/sda /sdNavigation.cfm?sd=labelingdatabase. Accessed November 6, 2013. 7. Ward RM, Kern SE. Clinical trials in neonates: a therapeutic imperative. Clin Pharmacol Ther. 2009;86(6):585-587. 8. Laughon MM, Avant D, Tripathi N, et al. Drug labeling and exposure in neonates [published
online December 9, 2013]. JAMA Pediatr. doi:10.1001/jamapediatrics.2013.4208.
premature babies (EUNO): a randomised controlled trial. Lancet. 2010;376(9738):346-354.
9. Ballard RA, Truog WE, Cnaan A, et al; NO CLD Study Group. Inhaled nitric oxide in preterm infants undergoing mechanical ventilation. N Engl J Med. 2006;355(4):343-353.
11. Pediatric studies of sodium nitroprusside conducted in accordance with section 409I of the Public Health Service Act; Establishment of Public Docket. Fed Regist. 2012;77(192):60441-60442. http://docs.regulations.justia.com/entries/2012-10 -03/2012-24213.pdf. Accessed November 6, 2013.
10. Mercier JC, Hummler H, Durrmeyer X, et al; EUNO Study Group. Inhaled nitric oxide for prevention of bronchopulmonary dysplasia in
The Beginning of the End of Measles and Rubella Mark Grabowsky, MD, MPH
Measles was first imported into the New World in the early 16th century by European colonists, often with devastating effects on native populations. Rubella importation followed and led to congenital rubella syndrome. It is estimated that during the following 5 centuRelated article page 148 ries, more than 200 million people globally died of measles. Disease incidence fell rapidly after the availability of vaccines in the United States for measles in 1963 and rubella in 1969, and after the availability of a combined measles-rubella vaccine in 1971. As vaccination expanded into other countries of the Americas, the Pan American Health Organization established a goal to eliminate measles from the Western hemisphere by 2002 and rubella by 2010. By 2004, transmission had been interrupted in the United States. However, there has been concern that pockets of transmission persisted or that transmission could be reestablished if immunization coverage levels declined. In this issue of the journal, Papania and colleagues1 report that an expert panel convened by the Centers for Disease Control and Prevention has determined that the elimination of endemic measles, rubella, and congenital rubella syndrome has been sustained for a decade. Along with certifications from other countries in the Americas, the entire Western hemisphere will be certified free of indigenous transmission. The elimination of measles and rubella from the Western hemisphere is a triumph of public health with several important implications. First, imported cases of measles and rubella will still likely occur as long as there remain endemic areas in the world. That these imported cases do not result in sustained transmission is confirmation that the level of population immunity is high enough for elimination. Prior to 1990, Mexico was the leading source of measles importations into the United States, but this year, half of all importations into the United States were from Europe.2 Since 2008, there has been a resurgence of measles cases in Western European countries. The majority of these outbreaks have been in unimmunized populations in countries where national immunization programs are being challenged by a combination of public and political complacency regarding the value of immunization and by the rising influence of antivaccination groups. After 500 108
years, we have now returned to a situation where the Americas are free from indigenous measles and rubella with Europe once again a source of importations. A second implication of the elimination of measles and rubella in the Western hemisphere is that it is a vindication of US vaccination strategy. Over the years, the United States experienced several false starts for measles and rubella elimination, with multiple missed target dates, but systematically incorporated the lessons learned from each failure into subsequent efforts.3 The essential elements of the final successful strategy were that (1) coverage with a first dose of measles-mumps-rubella (MMR) vaccine must be early, high, and sustained (in the United States, MMR vaccination rates among children younger than 2 years of age have been more than 90% for a decade); (2) each person must receive 2 doses of MMR vaccine (94.8% of children entering kindergarten have received 2 doses of MMR vaccine4); and (3) disease surveillance must include laboratory confirmation of suspected cases (there is a robust surveillance system for measles and genetic analysis of each virus to identify imported cases and their geographic source). It is encouraging that the European region has now endorsed these essential strategies, emphasizing routine vaccination and disease surveillance.5 The greatest threat to the US vaccination program may now come from parents’ hesitancy to vaccinate their children.6 Although this so-called vaccine hesitancy has not become as widespread in the United States as it appears to have become in Europe, it is increasing. Many measles outbreaks can be traced to people refusing to be vaccinated; a recent large measles outbreak was attributable to a church advocating the refusal of measles vaccination.7 Even greater risk may come from parents who delay vaccinations rather than refusing them outright because a delayed vaccination may add more personyears of susceptibility than that due to refusing vaccination. The single most important factor influencing decision making on childhood vaccination is the clear recommendation of a physician—clinicians must recognize their responsibility in supporting early vaccination. To address this issue, the National Vaccine Advisory Committee has convened a working group on vaccine hesitancy and has made some recommendations on how best to respond to it.
JAMA Pediatrics February 2014 Volume 168, Number 2
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a J H Quillen College User on 06/15/2015
jamapediatrics.com
Editorial Opinion
Although the effect of expanded measles immunization in the United States has been a substantial decrease in morbidity, a notable effect in developing countries has been a substantial decrease in mortality. The aim of Millennium Development Goal 4 is to reduce the overall number of deaths among children by two-thirds by 2015, compared with the level in 1990. There are now 550 000 fewer annual deaths from measles today than there were a decade ago. Fully one-fourth of all mortality reduction toward Millennium Development Goal 4 has been due to measles control.8 Over 30 African countries now have more than 80% measles vaccination coverage resulting in a 91% decline in measles mortality.9 The success of global measles and rubella control is largely due to an innovative partnership, the Measles-Rubella Initiative, which was started in 2001 and has since supported delivering more than 1 billion doses of vaccine. Special recognition is due to the American Red Cross, which convened and hosts the initiative, and its partners, the United Nations Foundation, the Centers for Disease ARTICLE INFORMATION Author Affiliation: Office of the Secretary General's Special Envoy for Financing the Health Millennium Development Goals and for Malaria, New York, New York. Corresponding Author: Mark Grabowsky, MD, MPH, Office of the Secretary General's Special Envoy for Financing the Health Millennium Development Goals and for Malaria, 650 Madison Ave, 22nd Floor, New York, NY 10022 (MGrabowsky @mdghealthenvoy.org). Published Online: December 5, 2013. doi:10.1001/jamapediatrics.2013.4603. Conflict of Interest Disclosures: None reported. REFERENCES 1. Papania MJ, Wallace GS, Rota PA, et al. Elimination of endemic measles, rubella, and congenital rubella syndrome from the Western hemisphere: the US experience [published online December 5, 2013]. JAMA Pediatr. doi:10.1001/jamapediatrics.2013.4342.
Control and Prevention, the United Nations Children’s Fund, and the World Health Organization. The ending of the measles and rubella pandemic in the Western hemisphere is a stepping stone to global eradication. There is a consensus that the global eradication of measles will proceed if there is progress toward these regional goals.10 Has such progress been made? With close to 20 million people, São Paolo in Brazil may be the largest city in the world. With an estimated population of 4 million people, Mexico City’s NezaChalco-Itza is considered to be the largest slum on the planet. New York City is one of the largest and most visited cities in the world. Disease transmission has such an advantage in these cities that it would seem implausible to control any infectious diseases, much less eliminate 2 of the most infectious ones. And yet, even in these settings, measles and rubella have been eliminated for a decade. The world need look no further for proof that global eradication of measles and rubella can be successful.
2. Centers for Disease Control and Prevention (CDC). Measles—United States, January 1–August 24, 2013. MMWR Morb Mortal Wkly Rep. 2013;62(36):741-743. 3. Hinman AR, Orenstein WA, Papania MJ. Evolution of measles elimination strategies in the United States. J Infect Dis. 2004;189(suppl 1):S17-S22.
immunization, and the risks of vaccine-preventable diseases. N Engl J Med. 2009;360(19):1981-1988. 7. Texas megachurch of center of measles outbreak [transcript]. Weekend Edition Sunday. National Public Radio. September 1, 2013. http://www.npr .org/2013/09/01/217746942/texas-megachurch -at-center-of-measles-outbreak. Accessed October 16, 2013.
4. Vaccines and immunizations: statistics and surveillance. Coverage with individual vaccines from the inception of NIS, 1994 through 2012. Centers for Disease Control and Prevention website. http://www.cdc.gov/vaccines/stats-surv /nis/figures/2012_map.htm. Accessed October 16, 2013.
8. Strebel PM, Cochi SL, Hoekstra E, et al. A world without measles. J Infect Dis. 2011;204(suppl 1):S1-S3.
5. World Health Organization. Measles and rubella elimination 2015: package for accelerated action: 2013-2015. http://www.euro.who.int/__data/assets /pdf_file/0020/215480/PACKAGE-FOR -ACCELERATED-ACTION-20132015.pdf. Accessed October 13, 2013.
10. World Health Organization. Global eradication of measles: report by the Secretariat. http://apps.who.int/gb/ebwha/pdf_files/WHA63 /A63_18-en.pdf. Published March 25, 2010. Accessed November 19, 2013.
9. Centers for Disease Control and Prevention (CDC). Progress in global measles control and mortality reduction, 2000-2006. MMWR Morb Mortal Wkly Rep. 2007;56(47):1237-1241.
6. Omer SB, Salmon DA, Orenstein WA, deHart MP, Halsey N. Vaccine refusal, mandatory
To Eat or Not to Eat What Foods Are Safe to Consume During Pregnancy? Ruchi Gupta, MD, MPH
Mothers-to-be often seek advice from physicians on what is safe to eat during pregnancy in order to give their child the best chance of being healthy. Historically, understanding the relationship between a woman’s diet during pregnancy and Related article page 156 neonatal outcomes has been critical to avoiding negative sequelae. Two well-known examples include the following: (1) adequate dietary folic acid intake to prevent neural tube defects1; and (2) avoidance of soft unpasteurized cheeses to pre-
vent Listeria infections, which can result in fetal death or other long-term consequences.2,3 With the recent increase in childhood food allergies,4 it is no surprise that women are seeking added guidance on whether diet during pregnancy can influence their child’s risk of developing food allergy. Yet, guidelines, experts, and the science itself continue to change at a rate that leaves women confused. For example, recommendations regarding the ingestion of potentially allergenic foods during pregnancy have flipflopped for more than a decade. Although guidelines in 2000
jamapediatrics.com
JAMA Pediatrics February 2014 Volume 168, Number 2
Copyright 2014 American Medical Association. All rights reserved.
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109
