This Thanksgiving, Let Us All...

This Thanksgiving, let us all give praise,

To those who guide our children through life's maze.

For pediatricians, heroes in their field,

Their love and care, an unbreakable shield.

President's Column

Nicole Webb, MD, FAAP

I hope everyone is enjoying the fall and finding a manageable cadence as respiratory illnesses start to pick up. It is that subject I want to talk about this month.

Whether you’re a recent grad or a vintage doc, generalist or cardiologist, we all know RSV and how far-reaching its effects on child health, and correspondingly on family and community health, are. RSV is the leading cause of hospitalization for infants. As a hospitalist, I have already started seeing cases and I imagine you have too. Though RSV causes a mild infection in most cases, it leads to hospitalization in up to 3% of infants, and as many as 300 deaths annually. 

Up until this point, primary prevention and palivizumab have been our only options. Needless to say, we’re all very excited about nirsevimab. It is a recombinant human monoclonal antibody to the RSV F (fusion) protein. The F protein is necessary for cell infection, so disabling it – which is what nirsevimab does – means the virus cannot infect host cells and propagate infection. Studies have demonstrated significant reduction in both RSV-associated LRTI (lower respiratory tract infection) and in hospitalization. For more information on how nirsevimab works, see this article.

There are several critical differences between nirsevimab and palivizumab. First, it has a considerably longer duration of action, which means that it only needs to be administered once during or before RSV season, rather than 5 times. It also, critically, has been shown to be effective at reducing illness and hospitalization in healthy babies and not just high-risk infants. This means the potential disease prevention impact, and associated savings in lost wages and all the attendant consequences of severe illness and hospitalization, are a lot greater.

Nirsevimab is approved by the FDA and recommended by the CDC for all infants under 8 months of age during their first RSV season and certain high-risk infants aged 8-19 months in their second RSV season. You can find a great quick reference guide to nirsevimab from the AAP here.  

As exciting as this is, what has been very apparent is that there are significant challenges with operationalizing the distribution and ultimate administration of nirsevimab, and these challenges will no doubt have inequitable consequences for kids. It is recommended for all newborns for their first RSV season and is approved for VFC (Vaccines for Children) at a slightly reduced cost of $395/dose (vs $495 for private sector), yet only 10% of birthing hospitals participate in VFC. This almost certainly means most babies will not receive it during their birth hospitalization. To counteract this, the CDC announced that it is allowing birthing centers who participate in VFC to carry a more limited array of vaccines, such as hepatitis B and nirsevimab, rather than all of the vaccines in the VFC formulary. While this may encourage some birthing centers to become VFC providers, significant concerns about uptake remain.

The AAP has been very proactive in identifying concerns with ordering, distribution, administration and reimbursement, and in pointing out the very real implications from a health equity perspective. AAP President Dr. Sandy Chung highlighted these concerns in a letter to the CDC Director, Dr. Mandy Cohen. Many of us were able to join a webinar recently with Dr. Cohen and other CDC leaders, moderated by Dr. Chung and AAP CEO Mark Del Monte, discussing nirsevimab as well as updated recommendations for COVID vaccination in kids. 

Dr. Cohen and her team agreed that ensuring equitable access to nirsevimab is a priority. One strategy to promote this is relaxing the requirement that VFC providers who only care for Medicaid-eligible children also purchase private stock. The other is to allow borrowing between VFC and private stock of nirsevimab. This is critical given the significant challenges and uncertainties regarding ordering and distribution. For more information on the new flexibilities for VFC approved by the CDC, refer to this AAP News article. Another significant concern regarding nirsevimab has been reimbursement for counseling and administration, given that it is approved as a medication and not a vaccine. Thankfully, the AMA has approved 2 codes for this, which you can read more about here.

We are very grateful to those of you who have already shared challenges with operationalizing offering nirsevimab to your patients, and we are working closely with national AAP as well as with AAP California to advocate for all of you, and for the kids and families we serve. Unfortunately, we know there are likely many challenges ahead, and we ask you to continue sharing those with us so that we may elevate your voices and advocate on your behalf. 

The AAP’s website Respiratory Syncytial Virus (RSV) Prevention has great resources for nirsevimab and palivizumab, which will continue to be important especially this season as we work through challenges with nirsevimab. This includes all the resources linked above. We encourage you to refer to that, and to let us know how we can help.

Thank you for all that you do.

Come Join Us Dec. 2 at the California Academy of Sciences!

Mika Hiramatsu, MD, FAAP

Chair, Continuing Medical Education (CME) Committee

Our upcoming Puzzles CME meeting is now two-thirds sold out.  Don’t wait any longer to sign up.  We decided to host a family-friendly event this year and avoid the traffic and congestion around Mission Bay.  Our event will start at 8:30 a.m. and end by 2:30 p.m., giving attendees 2.5 hours to visit the museum if they choose. Good news! Your meeting registration will include admission for you to the Academy! You may purchase additional tickets through the Cal Academy website. If dinosaurs, fish and rocks aren’t your or your kids’ thing, there is lots to do within walking distance of the Academy, including the DeYoung Museum and its observation tower overlooking the City and Golden Gate Bridge, the giant Ferris Wheel, the Japanese Tea Garden (https://www.japaneseteagardensf.com), and of course the many paths of Golden Gate Park.  The DeYoung Museum offers Free Saturdays to all residents of the 9 Bay Area counties.  More information here: https://www.famsf.org/events/free-saturdays-de-young.

Puzzles topics were chosen by popular demand:  sports medicine and physical therapy, behavior/development and psychiatry, and your favorite — dermatology.  We are fortunate to have engaged terrific speakers, including much-respected and recently retired Dr. Renee Howard.  Dr. Emily Kraus (sports medicine), Dr. Timothy Liu (DPT), Dr. Lisa Benton-Hardy (psychiatry) and Dr. Neal Rojas (behavior and development) round out the day.

Because you’ll be arriving early, there may be street parking, but the Academy garage runs by the hour to a max of $33/day.  The UCSF medical center garage is $24/day.  It’s also convenient to take BART and the N-Judah MUNI line if you are considering public transportation.

Due to limited space in the conference room, we won’t have classroom-style seating.  So be prepared to host your laptop actually on your lap, or bring a pen to take notes on paper (*gasp*).  

Come and be reminded why education is better in-person!  

The CME committee looks forward to seeing you in the City by the Bay December 2.

Developing Concerns

Renee Wachtel, MD, FAAP

Chair, Committee on Developmental and Behavioral Pediatrics

Accessing Mental/Behavioral Health services for our patients has been a difficult issue for pediatricians for years, and this seems to be getting worse, for both patients with private insurance and those with Medi-Cal. Surveys of pediatricians routinely complain about the complexity of finding appropriate and available therapists that have expertise in the specific needs of our patients and their families. For families with Medi-Cal, Mental Health services have been divided between the Managed Care Organizations (MCOs) and the County Mental Health Programs (MHPs). The MCOs have been responsible for “mild-moderate” mental health needs and the County MHPs have been responsible for “moderate-severe” mental health needs. 

Some changes that have occurred recently through the “California Advancing and Innovating Medi-Cal (Cal-AIM) process, while attempting to improve the situation, have in fact made it worse. Specifically, the Department of Health Care Services (DHCS) has developed a “Mental Health Screening Tool for Children and Youth”, which MCOs and MHPs are required to use to determine which agency will complete a clinical assessment for children and youth referred for mental health services. Our CA American Academy of Pediatrics has been working with the state to revise the tool, which we feel is not properly directing children and youth to the appropriate agency to complete an assessment of their mental health needs. In addition, physician referrals were no longer considered in this determination. 

Fortunately, the state has heard our concerns, and as of July 2023 physician referrals will no longer need to be “second guessed” and the screening tool is no longer required for these referrals. We are still trying to work with the state to improve the tool. But pediatricians should be aware that children and youth who are in foster care, whose families are homeless, or have involvement with juvenile justice should be referred directly to the County MHP for mental health services. Many County MHPs also have mobile crisis programs for children and youth, but often operate only Monday to Friday due to staffing and financial issues. We need to advocate for these services to be expanded as well. Advocating for our patient’s needs is an important part of AAPCA1’s mission. Stay tuned.

Data Exchange Updates

Resham Kaur, MD, FAAP

Project Lead, Data Exchange Framework

DSA SIGNATORY GRANTS

• The DSA (Data Sharing Agreement) Signatory Grants Round 3 application window is open from October 16 to December 15. Organizations who have signed the DSA and have a health information technology (HIT) need to enable exchange under the DxF are strongly encouraged to apply for a Technical Assistance (TA) grant or QHIO  (Qualified Health Information Organization) Onboarding grant. 
• Bi-weekly office hours will be hosted to provide direct application support to interested applicants.  The first office hour session was held on November 1, 2023 from 12:00 PM - 1:00 PM PT.  
• Interested applicants are encouraged to review the updated DSA Signatory Grants Guidance Document and the DSA Signatory Grants Application Template. 
• Below are links to DxF Grant Program resources available on CDII’s DxF web page. 
• Apply via the DxF Grants Portal 
• Grants Program Overview 
• DSA Signatory Grants Guidance Document (Updated October 2023) 
• DSA Signatory Grants Application Template (Updated October 2023) 
• DSA Signatory Grants Round 1 and 2 Awardees 

QHIO ANNOUNCEMENT

California Health & Human Services Agency (CalHHS) and Center for Data Insights and Innovation (CDII) have  announced that nine (9) organizations have met the requirements to be designated as Qualified Health  Information Organizations (QHIOs) in the Data Exchange Framework (DxF). These organizations are available  to DxF Participants seeking assistance in meeting their DxF exchange obligations. 

• Applied Research Works, Inc. 
• Health Gorilla, Inc. 
• Long Health, Inc. 
• Los Angeles Network for Enhanced Services (LANES) 
• Manifest MedEx 
• Orange County Partners in Health-Health Information Exchange (OCPH-HIE) 
• SacValley MedShare 
• San Diego Health Connect 
• Serving Communities Health Information Organization (SCHIO) 

The designation of QHIOs marks a major step in the implementation of the DxF by identifying organizations  that can provide the assistance Data Sharing Agreement (DSA) Signatories may need to participate in the DxF.  For many, exchange under the DxF begins on January 31, 2024. 

Visit CDII’s DxF Web page to learn more about the QHIOs or see the press  release about this DxF milestone. 

If you have questions or want more information, visit the DxF Page on our website or contact info@aapca1.org.

For the most up-to-date information on AAP California bill positions, letters, and outcomes from the current California Legislative year, go to www.aap-ca.org/bill. For the latest organizational advocacy updates follow @AAPCADocs on Twitter. If you have questions and/or are interested in knowing more about certain legislation, reach out to our State Government Affairs Chapter Representative Nora Pfaff, MD, FAAP and Anna Kaplan MD, FAAP at info@aapca1.org. 

Announcing The Pediatric Environmental Health: e-Toolkit for Prevention (PHET)

Do you get questions from parents about environmental health topics such as PFAS or heavy metals in baby foods or air pollution? The PEHT is here to help! The Pediatric Environmental Health:  e-Toolkit for Prevention is a FREE mobile-friendly set of online tools aimed at pediatric healthcare providers. You can search for topics by specific chemicals (like lead) or by the substance the kid is/could be exposed to (like baby foods). There is environmental health anticipatory guidance grouped by age, to complement bright futures, and key concepts to help you quickly build foundational knowledge in environmental health.

For every topic in the PEHT, we also have a companion Prescriptions for Prevention - an online handout you can provide parents on preventing exposures and health effects. There are even some videos! (English versions of the handouts and videos are available now, with Spanish following soon.

The Pediatric Environmental Health Specialty Units (PEHSUs) have created and maintained this resource, with the completely updated and revised 3rd edition. For more information on pediatric environmental health, reach out to your local PEHSU.

Gender Journeys: A Primer for Primary Care - Wednesday, November 8, 6:30 pm - 8:30 pm

Facilitated by Chandani DeZure, MD - AAP-CA3’s Equity, Diversity, and Inclusion Champion, and Maya Kumar, MD, AAP-CA3’s Adolescent Health Chair, this is a free CME event for healthcare providers. 2.0 CME and 2.0 MOC Part 2 offered for this event. The speakers are from UC San Diego’s Center for Gender Affirming Care. 

You can register for this event here.

Introducing a New Leadership Training Program for Early Career Physicians! - Apply by Nov. 12

The AAP Section on Early Career Physicians (SOECP) is thrilled to announce the launch of our leadership program designed to empower and inspire future leaders: Early Career Leadership Alliance (ECLA)!

What is the Early Career Leadership Alliance? In line with Goal 3 of the AAP Equity Agenda, the Early Career Leadership Alliance (ECLA) is a 2-year training initiative crafted to cultivate leaders and foster a community of leadership among physicians, with a particular emphasis on supporting our members that are underrepresented in medicine (URIM). Building upon the successes of the Young Physicians Leadership Alliance (YPLA), a program facilitated by the SOECP from 2015 to 2022, the ECLA is uniquely designed with an equity lens, recognizing that access to leadership training and support may not be equally available to physicians historically underrepresented in medicine. This program is a strategic response to the imperative for URIM members to receive tailored programming, coaching, and structural support to attain their objectives, aligning with both the participants' goals and the Academy's objectives for workforce diversity and health equity. 

Key Program Highlights: 

• Virtual components designed to disseminate content and foster opportunities for reflection and connection-building 
• Curriculum will encompass a diverse array of topics, including (but not limited to): advocacy principles tailored for pediatricians, leveraging influence for impactful change, pathways to leadership, cultivating a culture of wellness, utilizing narrative medicine as a wellness tool, and the dynamics of giving and receiving mentorship.  

Applications Are Now Open! Applications are currently open for the following opportunities (click on the links below for more information and to apply). We welcome applications from interested participants and faculty candidates until November 12. Notifications of acceptance will be sent to selected participants during the week of December 12. 

• ECLA Program Participants 
• ECLA Program Senior Faculty 
• ECLA Program Early Career Faculty 

Don't miss this opportunity to invest in your leadership development. We look forward to welcoming you to the Early Career Leadership Alliance (ECLA)! Should you have any questions about the ECLA and/or applications, please feel free to contact Elisha Ferguson, Manager, Early Career Engagement at eferguson@aap.org.

Diving into the Implications of ACEs on Interpersonal Relationships and Healthcare - Tuesday, November 14, 11:30 am - 1:30 pm 

Join the Sierra Community Medical Foundation (SCMF) for a free virtual training on the effects of Adverse Childhood Experiences (ACEs) on interpersonal relationships, as it relates to the health of adults, children, couples, and families. The workshop is intended for physicians and other healthcare workers interested in learning to properly engage with and treat patients with a history of ACEs.

As part of our ACEs / Social Determinants of Health Coalition, SCMF aims to educate healthcare workers on Adverse Childhood experience (ACEs), which are potentially traumatic events that occur in childhood. ACEs can include violence, abuse, and growing up in a family with mental health or substance abuse problems. Toxic stress from ACEs can change brain development and affect how the body responds to stress. ACEs are linked to chronic health problems, mental illness, and substance misuse in adulthood. (Source: cdc.gov)

Our experienced presenters will offer their valuable perspectives and insights on ACEs in healthcare, providing attendees with an opportunity to understand the topic more holistically.

• Dr. Michele Evans, Northern California Regional Medical Director, Kaiser Permanente Child Abuse Services and Prevention
• Dr. Craig Corp, SCMF Medical Director, Sutter Health Pediatrician
• Camesha Harper, LCSW, Behavioral Health Program Manager, Peach Tree Health

The presentations will be followed by a Q&A/discussion.

You can access the Zoom meeting through this link. We still have slots available, so please invite anyone who would benefit from attending this workshop! They may register through bit.ly/AttendACEs.

TBD - The Balance Between Data Exchange and Privacy: Ask the Experts!

December 2 - 8th Annual Pediatric Puzzles CME Conference at the California Academy of Sciences! - REGISTER HERE!

December 8-10 - 2023 Las Vegas Seminars - REGISTER HERE!

Executive Committee:

President: Nicole Webb • Vice President: Neel Patel

• Secretary: Resham Kaur • Treasurer: Amita Saxena • Past President: Nelson Branco

Executive Director: Yolanda Ruiz

Board Members:

North Valley MAL: Thiyagu Ganesan • Sacramento Valley MAL: Lena van der List • Central Valley MAL: Deborah Shassetz • South Valley MAL: Sireesha Palkamsetti • San Francisco MAL: Maya Raman • Santa Clara MAL: Bindya Singh• San Mateo MAL: Jackie Czaja • North Coastal MAL: Jeffrey Ribordy • Monterey Bay MAL: Graciela Wilcox • Alameda MAL: Renee Wachtel • Contra Costa/Solano MAL: Omoniyi Omotoso

Pediatric Insider News Editors:

• Mika Hiramatsu • Deborah Shassetz • Alyssa Velasco

Staff:

• Project Coordinator: Sana Sayyid