2019 - May Edition
Alice Kuo, MD, PhD, MBA, FAAP   President, AAP-CA2    2018 - 2020 
President's Message
I am guessing that many of you have been overwhelmed by questions about measles from your patients and parents (as I have been) since the news broke on April 22 of confirmed cases of measles in Los Angeles County. Given the widespread number of cases in the U.S. this year, it was just a matter of time until this infection reached Los Angeles. Please check out the article below by Ken Zangwill, MD, Chief of Pediatric Infectious Diseases at Harbor-UCLA and member of the Executive Committee of the Section on Infectious Diseases at National AAP. In it, you will find a summary of the vaccination guidelines for measles vaccines for infants, toddlers and children, along with recommendations for adults. If you are concerned about a possible measles exposure, PLEASE call the LA County Department of Public Health immediately at 213-351-7800 or call ahead to the clinic or emergency room you are sending a patient to, so that the facility can prepare to minimize potential exposures to other patients.
Although the news and concerns about the measles are overshadowing our offices at the moment, pertussis outbreaks continue in local school districts, particularly involving middle and high school students who are likely immunized but have waning immunity due to the weaker nature of the acellular form of the vaccine. In March, there were around 80 confirmed cases in 12 schools in the West Los Angeles area. Unfortunately, in mid-April, an infant died of pertussis in Orange County. Remember, the reason for population-level pertussis immunization is to protect the babies who are either not yet immunized or under-immunized, for whom pertussis can be fatal. Also, please remember that if you have a confirmed case of pertussis, that the child must complete five (5) full days of antibiotics before going back to school in order not to spread the disease. They may continue to cough for several months after treatment, but they are no longer contagious if they complete five days of antibiotics.
In their article on "Effectiveness of pertussis vaccination and duration of immunity" published in 2016, Schwartz et al. examined pertussis immunity with acellular pertussis vaccine following a localized outbreak in Ontario, Canada during 2012. They used a case control study design to look at 5867 children who had been immunized between 2009 and 2013 (486 who had tested positive for pertussis and 5381 who had tested negative) and found that the vaccine conferred 84% immunity up to 3 years, but then dropped to 62% from 4-7 years, and 41% at 8 or more years (click here for a copy of the original article). In light of this and ongoing outbreaks in the county, I am hearing of pediatricians' being pressured by parents to give additional Tdap boosters to children 7-10 years and 14+ years who fall in this period of waning immunity. While this is not an official recommendation of the ACIP or AAP Red Book Committee, I can see the reasoning, particularly as pregnant women are given Tdap with every pregnancy, and parents are understandably concerned about ongoing cases of pertussis in local communities. Our chapter is partnering with LA County DPH to study this issue--please contact Tomas if you are interested in getting involved.
Later this month, we are hosting a Strategic Forum with First 5 Los Angeles to address the Help Me Grow initiative in Los Angeles County. In our chapter, Help Me Grow initiatives have been launched in San Luis Obispo, Ventura, Kern, San Bernardino and Riverside counties, in addition to Los Angeles (click here for a link to the Help Me Grow California website). The Help Me Grow initiative helps communities leverage existing resources to identify vulnerable children, link families to community-based services, and empower families to support their children's healthy development. Our involvement as pediatricians in Help Me Grow is crucial because we are uniquely positioned to identify developmentally vulnerable children through developmental monitoring during well-child visits. This work builds upon the efforts of Ed Curry during his time as Chapter President where he championed training pediatricians on developmental screening. Please join us for this important Strategic Forum (details below).
Our chapter is also getting to know our new state Surgeon General, Nadine Burke Harris. Tomas and I were invited to Chapter 4's Trauma Informed Care conference in Anaheim on April 5 and 6 and had the opportunity to meet and chat with her about her future plans for the state. I also had an opportunity to be involved in her Listening Tour, where she is meeting with community members to hear from them the struggles to provide trauma-informed care to children in low-income communities and in foster care. Dr. Burke Harris outlined her top three priorities as addressing Adverse Childhood Experiences (ACEs), toxic stress, and health equity. In our own chapter, we are launching our ACEs Committee with Adam Schickedanz from UCLA, Ruby Kalra from Kaiser Downey, Ariane Marie-Mitchell from Loma Linda, Stephanie Marcy from CHLA and Danielle Shaw from Camarillo. Please click here if you are interested in joining our ACEs Committee and being part of the Surgeon General's initiatives for California.
Did you know that AB 1433 (signed into law in 2005) requires that all kindergarteners in the state have an oral health exam prior to May of their kindergarten year? This law was updated in 2018 to use Prop 56 funds to provide more oversight at the state level and collect data on whether and how this is happening. Last month, I attended a Board Meeting for our local Dental Transformation Initiative, called More L.A. Smiles (details below). Please check out their website for opportunities for CME and MOC related to pediatric oral health, as well as more information on this kindergarten dental registry.
As you can see, our chapter is very active addressing child health issues and supporting all of our work as pediatricians. Now is a good time to reach out to your pediatric colleagues who have not yet joined the chapter or paid their chapter dues. If there are pediatricians you know who would be willing to join the chapter, please direct them to our membership site (here). Also, it is possible to join our chapter to support local child health efforts without joining national AAP if there are cost prohibitions. Please contact Tomas for more information.
Please check out the rest of our newsletter for information on our Town Hall meetings and other CME opportunities, ways to get Maintenance of Certification (MOC) points with Quality Improvement (QI) projects, and statewide advocacy priorities that the AAP is working on behalf of children.
Thanks for all that you do on behalf of children in our communities!
Alice Kuo, MD, PhD, MBA, FAAP
Chapter President
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Measles - Update
Ken Zangwill, MD, FAAP
Chief, Div of Pediatric Infectious Diseases
Director, Infection Prevention and Control
Harbor-UCLA Medical Center
Professor of Pediatrics
Geffen School of Medicine at UCLA

As of May 1 more people with measles have been reported in the U.S. in 2019 than in any of the last twenty-five years. Over 70% have occurred in those that are unvaccinated and nearly 10% of all cases were hospitalized. Nearly 90% of cases are linked to closed communities that shun vaccine, now exacerbated by others in the community who also refuse vaccine. At least 6 cases have been identified in Los Angeles county residents along with five other through-traveler cases. Many providers are too young to have seen a case. One of the most contagious infections known, measles presents with (often high) fever, cough, coryza, conjunctivitis and a rash that starts at the head and moves down. The fever typically precedes the rash. After a couple days of a febrile illness, Koplik spots appear just before or coincident with the exanthem. Children with measles are usually rather irritable and "sick". Patients are contagious from 4 days prior to and 4 days after the onset of rash.    
Vaccination is the best protection. As a reminder, routine measles vaccination occurs at 12-15 months of age and then again at 4 to 6 years of age. The first dose is scheduled to avoid interference with maternal antibody and the second dose timing takes advantage of the pre-school entry primary care visit which happens at 4-6 years of age. It is completely acceptable, however, to give the second dose well before 4-6 years of age so long as the dose is at least 28 days after the first. This second dose "counts" as a part of the routine measles vaccination schedule. Infants 6 to <12m of age may be considered for vaccination if they are to soon travel to an endemic area. If given at this age, however, the dose NOT count towards completion of the routine series (ie. the child still needs a dose at 12-15 months of age and the second dose at least 28 days thereafter.
Adults born before 1957 are considered to have had wild-type measles and immune. Otherwise low-risk adults are considered immune if they have evidence of antibody or have received at least 1 dose of vaccine. Those at higher risk of acquisition or morbidity if infected (healthcare workers, international travelers, those in post-high school educational settings, immunocompromised) are recommended to receive two vaccine doses, at least 28 days apart (if they do not otherwise have serologic evidence of immunity).
If you see a patient you suspect may have measles, immediately put a surgical mask on the patient, isolate them within the office as best you can, and call the health department. Public Health will help you work out the management process thereafter.   

April 26 Update
Measles Prevention  
in LA County
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Measles Resources
  • Laboratory Guidance
  • Clinical Guidance 
  • Disease Investigation, and more

Upcoming AAP-CA2 Events  -  Save The Date

May 29 - Strategic Forum in Los Angeles

With First 5 LA being so close to Union Station, we recommend taking public transit to the forum. You can plan before you go with  LA Metro Trip Planner .
If you plan to drive, parking will be validated for Gateway Center parking ONLY. The Gateway Center is located at 801 N. Vignes St, Los Angeles, CA 90012 (location #1 on this Parking Map)

June 4 - Town Hall in Woodland Hills
Ken Saul, MD, FAAP AAP-CA2 Member-At-Large
Join AAP-CA2 Member-At-Large Ken Saul, MD, FAAP for an evening of professional development and networking.
Topic: What's New With Probiotics 
Speaker: Tracy Shafizadeh, PhD     
Date: Tuesday, June 4,2019
Time: 6:30 PM 
Location: Maggiano's Little Italy 
6100 Topanga Canyon Blvd, Woodland Hills, CA 91367
RSVP by emailing to Dr. Saul:
Advocacy Updates

Ban on Sale of Tobacco Products
The City of Beverly Hills Health and Safety Commission recommendations regarding a potential ban on the sale of all tobacco products in Beverly Hills will be presented to City Council on TUESDAY, MAY 7, 2019 AT 7:00 PM at the Formal Session meeting. The council will take public comments. View the Agenda here
Please REGISTER HERE if you are able to attend.  

Smoke Control - Multi-Unit Housing
Seeking Pediatrician in Favor of Smokefree Policies
City of Los Angeles Councilmember Paul Koretz has introduced a motion about passing a law that would regulate smoking in multi-unit housing in the city of Los Angeles. According to the CDC, more than 1/3 of apartment residents are breathing a neighbor's tobacco smoke. Thousands of surveys conducted by SAFE in the last 15 years (With funding from the California Department of Public Health) showed the same results.  
A group of health organizations including the American Lung Association, the American Cancer Society, the  UCLA Center for Health Policy Research, and SAFE have been working with the office of Councilmember Koretz via his legislative deputy, Jeff Ebenstein in support of the motion. Read more  
The office of Councilmember Koretz hopes that a pediatrician could join the next meeting (June 19 at noon at LA City Hall) of the health organizations and Tenants' Rights groups to join the effort to protect LA's children who live in apartments from tobacco and marijuana smoke. Are you interested? Register here 
Dental Transformation Initiative
In a state-funded effort to improve the oral health of Los Angeles County children on Medi-Cal, UCLA's More LA Smiles Dental Transformation Initiative invites medical providers and their staff to participate in clinical trainings and quality improvement (QI) programs. Provided by UCLA faculty in collaboration with various program partners, the free education equips providers to deliver pediatric risk-based prevention and disease management services.  
The innovative and nationally recognized curriculum includes:
This 6-month program focuses on integrating oral health preventative services in well-child visits for children ages 0-6. This includes a 1-hour training for providers and clinical staff, followed by technical assistance and implementation support.
PCPs receive additional reimbursement from Medi-Cal for applying fluoride varnish, and earn 30-50 CME and 20-25 MOC Part IV credits for participation.
Overview Training: This 1-hour training explains the Medi-Cal 2020 Dental Transformation Initiative and provides contemporary understanding of dental caries and systems-based approaches to improving children's oral health. Participating providers may earn 1 CME credit online or can request an in-person training for their office by visiting www.morelasmiles.org.
Advanced Training: The 3-hour training includes in-depth instruction on performing caries risk assessments, applying fluoride varnish, utilizing self-management goals and contemporary approaches for prevention and management of dental caries as a chronic infectious disease. Participating providers earn 3 CME credits at a UCLA event or via webinar. Email morelasmiles@ucla.edu to register for Tuesday, JUNE 4th 6pm - 9pm at UCLA or via webinar or learn about future trainings. 
Join today!
Stay Connected!  @moreLAsmiles    
Previous Issues  - Peds@CA2 e-News 

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Other Events  -  Community Partners
Friday, May 17 | Temecula
Maternal Mental Health Film Screening
Cosponsored by March of Dimes

Friday, May 31, 2019 | CHLA
9:30am - 3pm

CDC Updates & LAHAN Alerts
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Please contact Tomás Torices, MD (Chapter executive director) for all Chapter 2 related matters.
Cell. (818) 422-9877
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