Estimated Public Health Impact of the Recombinant Zoster Vaccine

OBJECTIVE

To investigate the potential public health impact of adult herpes zoster (HZ) vaccination with the adjuvanted recombinant zoster vaccine (RZV) in the United States in the first 15 years after launch.

METHODS

We used a publicly available model accounting for national population characteristics and HZ epidemiological data, vaccine characteristics from clinical studies, and anticipated vaccine coverage with RZV after launch in 2018. Two scenarios were modeled: a scenario with RZV implemented with 65% coverage after 15 years and a scenario continuing with zoster vaccine live (ZVL) with coverage increasing 10% over the same period. We estimated the numbers vaccinated, and the clinical outcomes and health care use avoided yearly, from January 1, 2018, to December 31, 2032. We varied RZV coverage and investigated the associated impact on HZ cases, complications, and health care resource use.

RESULTS

With RZV adoption, the numbers of individuals affected by HZ was predicted to progressively decline with an additional 4.6 million cumulative cases avoided if 65% vaccination with RZV was reached within 15 years. In the year 2032, it was predicted that an additional 1.3 million physicians' visits and 14.4 thousand hospitalizations could be avoided, compared with continuing with ZVL alone. These numbers could be reached 2 to 5 years earlier with 15% higher RZV vaccination rates.

CONCLUSION

Substantial personal and health care burden can be alleviated when vaccination with RZV is adopted. The predicted numbers of HZ cases, complications, physicians' visits, and hospitalizations avoided, compared with continued ZVL vaccination, depends upon the RZV vaccination coverage achieved.

996. The Potential for Reducing Opioid and Analgesic Prescriptions Via Herpes Zoster Vaccination

Background

Herpes zoster (HZ), or shingles, is a common neurocutaneous disease caused by the reactivation of latent varicella zoster virus that often includes rash and neuropathic pain that may last for months. Opioids and other analgesics may be prescribed. Recombinant zoster vaccine (RZV) is preferentially recommended for the prevention of HZ in adults aged 50 years and older. This study aimed to assess the impact of RZV vaccination on opioid and other analgesic prescription-related outcomes.

Methods

Estimates of analgesic prescription rates (opioids, benzodiazepines, and other analgesics) among HZ cases were established using Truven claims data from 2012-2018 for adults aged 50 years and older. HZ case avoidance with RZV vaccination was calculated using a previously published cost-effectiveness model. This data was included in a calculator assessing the impact of RZV vaccination on analgesic prescription-related outcomes (compared to no vaccination).

Results

Between 24.4% and 28.0% of HZ cases in the observed claims had at least one opioid prescription, dependent on age group (4.5%-6.5% and 8.6%-19.6% for benzodiazepines and other analgesics, respectively). The mean number of opioid prescriptions per person in each age group with at least one opioid prescription was between 1.7 and 1.9 (1.7-2.3 and 1.7-2.0 prescriptions for benzodiazepines and other analgesics, respectively). Assuming a 1-million-person population and 65% RZV coverage, the calculator predicts RZV vaccination will prevent 75,002 cases of HZ and will prevent 19,311 people from being prescribed at least 1 HZ-related opioid, 4,502 people from being prescribed benzodiazepines, and 12,201 people from being prescribed other analgesics. Additionally, 34,520 HZ-related opioid prescriptions will be avoided (9,413 benzodiazepine prescriptions; 22,406 other analgesic prescriptions).

Conclusion

HZ is associated with high levels of opioid, benzodiazepine, and other analgesic use. Primary prevention of HZ by vaccination could potentially reduce opioid and other medication exposure.

Disclosures

Jean-Etienne Poirrier, PhD, MBA, The GSK group of companies (Employee, Shareholder) Justin Carrico, BS, GlaxoSmithKline (Consultant) Jessica K. DeMartino, PhD, The GlaxoSmithKline group of companies (Employee, Shareholder) Katherine A. Hicks, MS, BSPH, GlaxoSmithKline (Scientific Research Study Investigator, GSK pays my company for my contractual services.) Saurabh P. Nagar, MS, RTI Health Solutions (Employee) Juliana Meyers, MA, GlaxoSmithKline (Other Financial or Material Support, This study was funded by GlaxoSmithKline.)

Immunogenicity and safety of a respiratory syncytial virus fusion protein (RSV F) nanoparticle vaccine in older adults

Background

A preventative strategy for Respiratory Syncytial Virus (RSV) infection constitutes an under-recognized unmet medical need among older adults. Four formulations of a novel recombinant RSV F nanoparticle vaccine (60 or 90 μg RSV F protein, with or without aluminum phosphate adjuvant) administered concurrently with a licensed inactivated trivalent influenza vaccine (TIV) in older adult subjects were evaluated for safety and immunogenicity in this randomized, observer-blinded study.

Results

A total of 220 healthy males and females ≥ 60 years of age, without symptomatic cardiopulmonary disease, were vaccinated concurrently with TIV and RSV F vaccine or placebo. All vaccine formulations produced an acceptable safety profile, with no vaccine-related serious adverse events or evidence of systemic toxicity. Vaccine-induced immune responses were rapid, rising as early as 7 days post-vaccination; and were comparable in all formulations in terms of magnitude, with maximal levels attained within 28 (unadjuvanted) or 56 (adjuvanted) days post-vaccination. Peak anti-F protein IgG antibody levels rose 3.6- to 5.6-fold, with an adjuvant effect observed at the 60 μg dose, and a dose-effect observed between the unadjuvanted 60 and 90 μg regimens. The anti-F response persisted through 12 months post-vaccination. Palivizumab-competitive antibodies were below quantifiable levels (<33 μg/mL) at day 0. The rise of antibodies with specificity for Site II peptide, and the palivizumab-competitive binding activity, denoting antibodies binding at, or in proximity to, antigenic Site II on the F protein, closely paralleled the anti-F response. However, a larger proportion of antibodies in adjuvanted vaccine recipients bound to the Site II peptide at high avidity. Day 0 neutralizing antibodies were high in all subjects and rose 1.3- to 1.7-fold in response to vaccination. Importantly, the RSV F vaccine co-administered with TIV did not impact the serum hemagglutination inhibition antibody responses to a standard-dose TIV, and TIV did not impact the immune response to the RSV F vaccine.

Conclusions

RSV F protein nanoparticle vaccine induced increases in measures of functional immunity to RSV in older adults and demonstrated an acceptable safety profile. Adjuvanted formulations provided additional immunogenicity benefit as compared to increasing antigen dose alone. This trial was registered with ClinicalTrials.gov number NCT01709019.

Effective influenza vaccines for children: a critical unmet medical need and a public health priority

Seasonal influenza causes clinical illness and hospitalization in all age groups; however, conventional inactivated vaccines have only limited efficacy in young children. MF59(®), an oil-in-water emulsion adjuvant, has been used since the 1990s to enhance the immunogenicity of influenza vaccines in the elderly, a population with waning immune function due to immunosenescence. Clinical trials now provide information to support a favorable immunogenicity and safety profile of MF59-adjuvanted influenza vaccine in young children. Published data indicate that Fluad(®), a trivalent seasonal influenza vaccine with MF59, was immunogenic and well tolerated in young children, with a benefit/risk ratio that supports routine clinical use. A recent clinical trial also shows that Fluad provides high efficacy against PCR-confirmed influenza. Based on the results of clinical studies in children, the use of MF59-adjuvanted vaccine offers the potential to enhance efficacy and make vaccination a viable prevention and control strategy in this population.

Critical appraisal of a quadrivalent CRM(197) conjugate vaccine against meningococcal serogroups A, C W-135 and Y (Menveo) in the context of treatment and prevention of invasive disease

Worldwide, invasive meningococcal disease affects about 500,000 people annually. Case fatality in developed countries averages 10%, and higher rates are reported in less prosperous regions. According to the World Health Organization, the most important pathogenic serogroups are A, B, C, W-135, X, and Y. Clinical features of invasive meningococcal disease make diagnosis and management difficult. Antibiotic measures are recommended for prophylaxis after exposure and for treatment of invasive meningococcal disease cases; however, resistant strains may be emerging. Vaccines are generally regarded as the best preventative measure for invasive meningococcal disease. Polysaccharide vaccines against serogroups A, C, W-135, and Y using protein conjugation technology have clear advantages over older plain polysaccharide formulations without a protein component. The first quadrivalent meningococcal conjugate vaccine (MenACWY-D) was licensed in the US in 2005. More recently, MenACWY-CRM (Menveo^®) was licensed in Europe, the US, the Middle East, and Latin America. MenACWY-CRM uses cross-reactive material 197, a nontoxic mutant of diphtheria toxin, as the carrier protein. MenACWY-CRM offers robust immunogenicity in all age groups, with a tolerability profile similar to that of a plain polysaccharide vaccine. Given its potential for protecting persons from infancy to old age, MenACWY-CRM offers the opportunity to protect broad populations against invasive meningococcal disease. The most optimal strategy for use of the vaccine has to be assessed country by country on the basis of local epidemiology, individual health care systems, and need.

Ensuring the optimal safety of licensed vaccines: a perspective of the vaccine research, development, and manufacturing companies

Vaccine safety is increasingly a focus for the general public, health care providers, and vaccine manufacturers, because the efficacy of licensed vaccines is accepted as a given. Commitment to ensuring safety of all vaccines, including childhood vaccines, is addressed by the federal government, academia, and industry. Safety activities conducted by the vaccine research, development, and manufacturing companies occur at all stages of product development, from selection and formulation of candidate vaccines through postlicensure studies and surveillance of adverse-event reports. The contributions of multiple interacting functional groups are required to execute these tasks through the life cycle of a product. We describe here the safeguards used by vaccine manufacturers, including specific examples drawn from recent experience, and highlight some of the current challenges. Vaccine-risk communication becomes a critical area for partnership of vaccine companies with government, professional associations, and nonprofit advocacy groups to provide information on both benefits and risks of vaccines. The crucial role of the vaccine companies in ensuring the optimal vaccine-safety profile, often overlooked, will continue to grow with this dynamic arena.

Optimizing protection against meningococcal disease

Neisseria meningitidis is a leading cause of bacterial meningitis and septicemia in the United States. Vaccines directed against meningococcal disease must elicit high and persistent titers of bactericidal antibodies against prevalent meningococcal serogroups and be highly efficacious in preventing meningococcal infection. Currently, 2 quadrivalent (A, C, W-135, Y) vaccines-a polysaccharide meningococcal vaccine and a conjugate meningococcal vaccine-are licensed in the United States. Neither is approved for use in infants or toddlers younger than 2 years of age. Results of studies with an investigational quadrivalent (ACWY) meningococcal CRM(197) glycoconjugate vaccine in infants demonstrate that this vaccine has potential to protect this age group. The availability of an effective vaccine for routine universal infant immunization is particularly important because the incidence of invasive meningococcal disease is greatest in infants for all serogroups and because achievable vaccination rates are much greater for infants and young children than they are for adolescents.

Effectiveness of school-based influenza vaccination

BACKGROUND

Vaccination of children in school is one strategy to reduce the spread of influenza in households and communities.

METHODS

We identified 11 demographically similar clusters of elementary schools in four states, consisting of one school we assigned to participate in a vaccination program (intervention school) and one or two schools that did not participate (control schools). During a predicted week of peak influenza activity in each state, all households with children in intervention and control schools were surveyed regarding demographic characteristics, influenza vaccination, and outcomes of influenza-like illness during the previous 7 days.

RESULTS

In all, 47% of students in intervention schools received live attenuated influenza vaccine. As compared with control-school households, intervention-school households had significantly fewer influenza-like symptoms and outcomes during the recall week. Paradoxically, intervention-school households (both children and adults) had higher rates of hospitalization per 100 persons than did control-school households. However, there was no difference in the overall hospitalization rates for children or adults in households with vaccinated children, as compared with those with unvaccinated children, regardless of study-group assignment. Rates of school absenteeism for any cause (based on school records) were not significantly different between intervention and control schools.

CONCLUSIONS

Most outcomes related to influenza-like illness were significantly lower in intervention-school households than in control-school households. (ClinicalTrials.gov number, NCT00192218.)

Benefits of and barriers to large medical group practice in the United States

BACKGROUND

For decades, reformers argued that medical groups can efficiently provide high-quality care and a collegial professional environment. The growth of managed care and the movement to improve quality provide additional reasons for physicians to practice in groups, especially large groups. However, information is lacking on recent trends in group size and the benefits of and barriers to group practice.

OBJECTIVES

To identify benefits of and barriers to large medical group practice, and to describe recent trends in group size.

DESIGN, SETTING, AND PARTICIPANTS

Information on benefits and barriers was obtained from 195 interviews conducted during round 3 (2000-2001) of the Community Tracking Study with leaders of the largest groups, hospitals, and health insurance plans in 12 randomly selected metropolitan areas. Information on recent trends in group size was obtained from more than 6000 physicians in private practice in 48 randomly selected metropolitan areas via Community Tracking Study telephone surveys in 1997-1998, 1998-1999, and 2000-2001.

MAIN OUTCOME MEASURES

Benefits of and barriers to large group practice, as perceived by interviewees, and changes in percentages of physicians in groups of varying sizes.

RESULTS

Gaining negotiating leverage with health insurance plans was the most frequently cited benefit; it was cited 8 times more often than improving quality. Lack of physician cooperation, investment, and leadership were the most frequently cited barriers. Survey data indicate that 47% of private physicians work in practices of 1 or 2 physicians and 82% in practices of 9 or fewer, and that the percentage of physicians in groups of 20 or more did not increase between 1996 and 2001.

CONCLUSIONS

Current payment methods reward gaining size to obtain negotiating leverage more than they reward quality. However, barriers to creating large medical groups are substantial, and most private physicians continue to practice in small groups, although the size of these groups is slowly increasing.

Referral gridlock: primary care physicians and mental health services

BACKGROUND

Patients' barriers to mental health services are well documented and include social stigma, lack of adequate insurance coverage, and underdiagnosis by primary care physicians. Little is known, however, about challenges primary care physicians face arranging mental health referrals and hospitalizations.

OBJECTIVE

To examine how practice setting and environment influence primary care physicians' ability to refer patients for medically necessary mental health services.

DESIGN

Cross-sectional analysis using nationally representative survey data from the 1998 to 1999 Community Tracking Study physician survey. The overall survey response rate was 61%.

PARTICIPANTS

A 1998 to 1999 telephone survey of 6586 primary care physicians.

MEASUREMENTS

Primary care physicians' report of whether they could obtain medically necessary referrals to high-quality mental health specialists or psychiatric admissions.

RESULTS

Overall, 54% of primary care physicians reported problems obtaining psychiatric hospital admissions, and 54% reported problems arranging outpatient mental health referrals. Primary care physicians practicing in staff and group model HMOs were much less apt to report difficulties than physicians in solo and small-group practices (P <.001). Reports of inadequate time with patients (P <.001) and smaller numbers of psychiatrists in a market area (P <.01) also were associated with problems obtaining mental health referrals. Pediatricians were more apt to report problems than general internists (P <.001).

CONCLUSIONS

Primary care physicians face greater hurdles obtaining mental health services than other medical services. Primary care is an important entry point for mental health services, yet inadequate referral systems between medical and mental health services may be hampering access.

Hospitals' negotiating leverage with health plans: how and why has it changed?

OBJECTIVE

To describe how hospitals' negotiating leverage with managed care plans changed from 1996 to 2001 and to identify factors that explain any changes.

DATA SOURCES

Primary semistructured interviews, and secondary qualitative (e.g., newspaper articles) and quantitative (i.e., InterStudy, American Hospital Association) data.

STUDY DESIGN

The Community Tracking Study site visits to a nationally representative sample of 12 communities with more than 200,000 people. These 12 markets have been studied since 1996 using a variety of primary and secondary data sources.

DATA COLLECTION METHODS

Semistructured interviews were conducted with a purposive sample of individuals from hospitals, health plans, and knowledgeable market observers. Secondary quantitative data on the 12 markets was also obtained.

PRINCIPAL FINDINGS

Our findings suggest that many hospitals' negotiating leverage significantly increased after years of decline. Today, many hospitals are viewed as having the greatest leverage in local markets. Changes in three areas--the policy and purchasing context, managed care plan market, and hospital market--appear to explain why hospitals' leverage increased, particularly over the last two years (2000-2001).

CONCLUSIONS

Hospitals' increased negotiating leverage contributed to higher payment rates, which in turn are likely to increase managed care plan premiums. This trend raises challenging issues for policymakers, purchasers, plans, and consumers.

Financial incentives and physicians' perceptions of conflict of interest and ability to arrange medically necessary services

Many believe that physician payment mechanisms that include incentives to restrain utilization create conflicts of interest for physicians and result in the withholding of needed services. Pooled data from two rounds of the Community Tracking Study physician survey, a nationally representative telephone survey of physicians, are the basis of this analysis. We examine the association between explicit financial incentives linked to physician profiling and perceived conflict of interest, and the reported ability to obtain specific, medically necessary secondary services (referrals, hospitalizations and diagnostic imaging). Logistic regression models were employed to control for potentially confounding influences. After controlling for other factors, physicians subject to profiling linked with financial incentives were much less likely than physicians not affected by profiling to strongly agree that they can make clinical decisions in the best interests of their patients without the possibility of reducing their income. They were also less likely to report that they could always obtain selected medically necessary secondary services for their patients. Physicians subject to explicit financial incentives based on profiling are more likely than other physicians to perceive a conflict of interest. Physicians with financial incentives tied to profiling also experience greater difficulty obtaining medically necessary secondary services for their patients.

Physicians more likely to face quality incentives than incentives that may restrain care

Concerns that physician financial incentives may lead to withholding needed care have caught the attention of legislators, regulators and even the U.S. Supreme Court. While the spotlight has been on how health plans reimburse physician practices, this Issue Brief provides unique nationally representative data on physician practices' use of incentives, which have a more direct effect on physician behavior. According to 1999 data from the Center for Studying Health System Change (HSC), physicians are more likely to be subject to incentives that may encourage use of services, such as patient satisfaction (24 percent) and quality (19 percent), than to financial incentives that may restrain care, such as profiling (14 percent). The complexity of physician financial incentives and their relatively low prevalence raise questions about effective regulation and public reporting of their use.

Managed care in the doctor's office: has the revolution stalled?

OBJECTIVE

To assess trends in the involvement of US physicians with managed care.

STUDY DESIGN

Comparison of data from 2 consecutive rounds of a national survey.

METHODS

Longitudinal data were obtained from the 1996/1997 (n = 12,528) and the 1998/1999 (n = 12,304) rounds of the Community Tracking Study (CTS) Physician Survey, a large, ongoing nationally representative survey of US physicians involved in patient care. Indicators used to assess involvement with managed care included global measures of managed care participation, risk contracting, exposure to financial incentives, and impact of care management tools. Changes in these measures over the 2 study periods are reported. Analyses were conducted for all physicians, as well as for primary care physicians (PCPs) and specialists separately.

RESULTS

The percentage of practice revenue derived from managed care increased only modestly over the study period (from 42% to 45%). Mean numbers of managed care contracts per physician increased minimally (from 12 to 13). Trends in acceptance of capitation and exposure to financial incentives remained stable over the study period. Among PCPs, employment in staff/group health maintenance organizations declined slightly, whereas gatekeeping function increased modestly. Among care management tools, only treatment guidelines had a significantly increased impact on medical practice, primarily among PCPs (from 46% to 52%; P < .001).

CONCLUSIONS

Many aspects of managed care leveled off between 1996 and 1999 in ways not accurately reflected by plan enrollment patterns. This "flattening of the curve" trend appears to hold generally across multiple measures. A stalling of the managed care "revolution," if it is sustained, may portend future escalation in healthcare costs.

Managed care, professional autonomy, and income: effects on physician career satisfaction

CONTEXT

Career satisfaction among physicians is a topic of importance to physicians in practice, physicians in training, health system administrators, physician organization executives, and consumers. The level of career satisfaction derived by physicians from their work is a basic yet essential element in the functioning of the health care system.

OBJECTIVE

To examine the degree to which professional autonomy, compensation, and managed care are determinants of career satisfaction among physicians.

DESIGN

Cross-sectional analysis using data from 1996-97 Community Tracking Study physician telephone survey.

SETTING AND PARTICIPANTS

A nationally representative sample of 12,385 direct patient care physicians. The survey response rate was 65%.

MAIN OUTCOME MEASURE

Overall career satisfaction among U.S. physicians.

RESULTS

Bivariate results show that physicians with low managed care revenues are significantly more likely to be "very satisfied" than are physicians with high managed care revenue (P < .05), and that physicians with low managed care revenues are significantly more likely to report higher levels of clinical freedom than are physicians with high managed care revenue (P < .05). Multivariate analyses demonstrate that, among our measures, traditional core professional values and autonomy are the most important determinants of career satisfaction after controlling for all other factors. Relative income is also an important independent predictor. Multiple dimensions of professional autonomy hold up as strong, independent predictors of career satisfaction, while the effect of managed care does not. Managed care appears to exert its effect on satisfaction through its impact on professional autonomy, not through income reduction.

CONCLUSIONS

Our results suggest that when managed care (or other influences) erode professional autonomy, the result is a highly negative impact on physician career satisfaction.

Minority physicians' experiences obtaining referrals to specialists and hospital admissions

CONTEXT

Over the past 15 years, policy makers, healthcare providers, and researchers have focused their attention on understanding and reducing ethnic disparities in access to healthcare. Efforts to understand and reduce these disparities in access are driven by the wealth of studies that document significant differences in the health of ethnic minority groups in the United States.

OBJECTIVE

To assess differences in access to medical care from African American, Hispanic, and white physicians' perspectives.

DESIGN

Using the Community Tracking Study Physician Survey, a nationally representative survey of US physicians, this study assesses physicians' abilities to obtain medically necessary services for their patients. Physicians were asked how often they could arrange referrals to specialists and inpatient admissions for their patients.

RESULTS

Controlling for physician characteristics (eg, providing charity care, participation in managed care, Medicaid, and Medicare) and community characteristics (eg, average managed care participation, supply of hospital beds and specialists per capita) reduces the magnitude of differences between white and ethnic minority physicians. Nevertheless, after controlling for a wide range of practice and environmental characteristics, African American physicians were more likely to report problems obtaining hospital admissions, and Hispanic physicians were more likely to report problems obtaining referrals to specialists, compared with white physicians.

CONCLUSIONS

Disparities in ethnic minority physicians' abilities to get medical services for their patients exist. This study corroborates that ethnic disparities are not limited to gaining access to primary health services (eg, having a doctor visit or a usual source of medical care) but extend into the healthcare delivery system itself (eg, getting a referral or hospital admission).

Physicians pulling back from charity care

Physicians have long provided care to the medically indigent for free or at reduced rates. However, recent findings from the Center for Studying Health System Change (HSC) indicate that the proportion of physicians providing charity care dropped from 76 percent to 72 percent between 1997 and 1999. In the short term, most medically indigent people are still getting care. But policy makers should take note that reduced physician participation in charity care will hurt the poor if-as projected-growth in physician supply slows and the number of uninsured rises along with escalating health care costs. This Issue Brief discusses the extent of the decline in physician provision of charity care, the reasons for the decline and implications for the future of the safety net.

The impact of managed care on children's access, satisfaction, use, and quality of care

OBJECTIVE

To examine the impact of managed care on children's access, satisfaction, use, and quality of care using nationally representative household survey data.

DATA SOURCE

The 1996 Medical Expenditure Panel Survey (MEPS).

STUDY DESIGN

Bivariate and multivariate analyses are used to detect independent effects of managed care on access, satisfaction, utilization, and quality of pediatric health services.

DATA COLLECTION/EXTRACTION METHODS

Data were obtained from rounds 1, 2, and 3 of the 1996 MEPS. MEPS collects data on health care use, insurance, access, and satisfaction, along with basic demographic and health status information for a representative sample of the U. S. civilian, noninstitutionalized population. Our sample consists of 5,995 children between the ages of 0 and 17.

FINDINGS

Among the 18 outcome indicators examined, the bivariate analysis revealed only three statistically significant differences between children enrolled in managed care and children in traditional health plans: children enrolled in managed care were more likely to receive physician services, more likely to have access to office-based care during evening or weekend hours, and less likely to report being very satisfied with overall quality of care. However, after controlling for confounding factors, none of these differences remained statistically significant.

CONCLUSIONS

Our findings suggest that there are no statistically significant differences in self-reported outcomes for children enrolled in managed care and traditional health plans. This conclusion is provisional, however, because of limitations in the data set.

Providing pediatric subspecialty care: A workforce analysis. AAP Committee on Pediatric Workforce Subcommittee on Subspecialty Workforce

OBJECTIVE

To provide a snapshot of pediatric subspecialty practice, examine issues pertaining to the subspecialty workforce, and analyze subspecialists' perspective on the health care market.

BACKGROUND

Before the effort of the Future of Pediatric Education II (FOPE II) Project, very little information existed regarding the characteristics of the pediatric subspecialty workforce. This need was addressed through a comprehensive initiative involving cooperation between subspecialty sections of the American Academy of Pediatrics and other specialty societies.

METHODS

Questionnaires were sent to all individuals, identified through exhaustive searches, who practiced in 17 pediatric medical and surgical subspecialty areas in 1997 and 1998. The survey elicited information about education and practice issues, including main practice setting, major professional activity, referrals, perceived competition, and local workforce requirements. The number of respondents used in the analyses ranged from 120 (plastic surgery) to 2034 (neonatology). In total, responses from 10 010 pediatric subspecialists were analyzed.

RESULTS

For 13 of the subspecialties, a medical school setting was specified by the largest number of respondents within each subspecialty as their main employment site. Direct patient care was the major professional activity of the majority of respondents in all the subspecialties, with the exception of infectious diseases. Large numbers of subspecialists reported increases in the complexity of referral cases, ranging between 20% (cardiology) and 44% (critical care), with an average of 33% across the entire sample. In all subspecialties, a majority of respondents indicated that they faced competition for services in their area (range: 55%-90%; 71% across the entire sample); yet in none of the subspecialties did a majority report that they had modified their practice as a result of competition. In 15 of the 17 subspecialties, a majority stated that there would be no need in their community over the next 3 to 5 years for additional pediatric subspecialists in their discipline. Across the entire sample, 42% of respondents indicated that they or their employer would not be hiring additional, nonreplacement pediatric subspecialists in their field in the next 3 to 5 years (range: 20%-63%).

CONCLUSION

This survey provides the first comprehensive analysis to date on how market forces are perceived to be affecting physicians in the pediatric subspecialty workforce. The data indicate that pediatric subspecialists in most areas are facing strong competitive pressures in the market, and that the market's ability to support additional subspecialists in many areas may be diminishing.

Minority and nonminority pediatricians' care of minority and poor children

BACKGROUND

Although it has been established that minority physicians tend to see more minority and more poor or uninsured patients, pediatrics as a specialty has not been studied in this regard.

OBJECTIVE

To determine if minority pediatricians disproportionately provide care to minority children and to poor and uninsured children, relative to nonminority pediatricians, while controlling for possible confounding variables (socioeconomic background, sex, use of non-English languages in practice, and subspecialty training).

METHODS

In 1996, a stratified random sample of 1044 pediatricians, half of whom were underrepresented minorities (URMs) (African, Native, and Mexican Americans, mainland Puerto Ricans, and other Hispanics) and half of whom were Asian or Pacific Islanders, commonwealth Puerto Ricans, and whites (non-URMs), were surveyed about personal, practice, and patient characteristics.

RESULTS

Multivariate analyses reveal that, independent of other variables, being a URM pediatrician is significantly (P = .001) and positively associated with caring for a greater proportion of minority and Medicaid-insured or uninsured patients. Underrepresented minority pediatricians saw 24 percentage points more minority patients and 13 percentage points more Medicaid-insured or uninsured patients than did non-URM pediatricians.

CONCLUSIONS

Compared with what non-URM pediatricians report, URM pediatricians report caring for significantly (P =.001) more minority and poor and uninsured patients. Given the few pediatricians who are URM, non-URM pediatricians should be adequately prepared to provide care for minority patients, as the proportion of minority children is high and will be increasing significantly in the next several years. Most important, efforts to ensure a racially and ethnically diverse health care workforce should be greatly enhanced, as its diversity, and hence representativeness, will improve the health care system for all Americans.

The unmet health needs of America's children

OBJECTIVE

Unmet need for health care is a critical indicator of access problems. Among children, unmet need for care has special significance inasmuch as the failure to obtain treatment can affect health status and functioning in the near- and long-term. The purpose of this study was to present current prevalence estimates and descriptive characteristics of children with unmet health needs using nationally representative household survey data.

METHODS

We analyzed 4 years of National Health Interview Survey data spanning 1993 through 1996. Our analysis included 97 206 children <18 years old. Measures of unmet need for medical care, dental care, prescription medications, and vision care were obtained from an adult household member (usually the mother) responding for the child. Bivariate and multivariate analyses were used to assess the degree to which unmet need was related to the demographic and socioeconomic characteristics of the child and family.

RESULTS

Overall, 7.3% (4.7 million) of US children experienced at least 1 unmet health care need. Dental care was the most prevalent unmet need. After adjustment for confounding factors, near-poor and poor children were both about 3 times more likely to have an unmet need as nonpoor children (adjusted odds ratio [95% confidence interval] = 2.89 [2.52, 3.32], 3.0 [2.53, 3.56], respectively). Uninsured children were also about 3 times more likely to have an unmet need as privately insured children (adjusted odds ratio [95% confidence interval] = 2. 92 [2.58, 3.32]).

CONCLUSIONS

Despite the nation's great wealth, unmet health needs remain prevalent among US children. A combined public policy that addresses financial and nonfinancial barriers to care is required to reduce the prevalence of unmet need for health care.

The respective racial and ethnic diversity of US pediatricians and American children

BACKGROUND

Much effort has been directed toward increasing the training of physicians from underrepresented minority groups, yet few direct comparisons have examined the diversity of the racial/ethnic backgrounds of the physicians relative to the patient populations they serve, either currently or into the future. This has been particularly true in the case of pediatrics, in which little information has emerged regarding the racial/ethnic backgrounds of pediatricians, yet evidence points to ever-growing diversity in the US child population.

OBJECTIVE

We embarked on a comparative analysis to examine trends in the racial and ethnic composition of pediatricians vis-a-vis the patient population they serve, America's infants, children, adolescents, and young adults.

METHODS

Data on US pediatricians sorted by racial/ethnic group came from Association of American Medical Colleges distribution data and is based on the cohort of pediatricians graduating from US medical schools between 1983 and 1989 extrapolated to the total number of pediatricians actively practicing in 1996. Data on the demographic diversity of the US child population came from the US Census Bureau. We derived pediatrician-to-child population ratios (PCPRs) specific to racial/ethnic groups to measure comparative diversity between and among groups.

RESULTS

Our results show that the black PCPR, currently less than one third of the white PCPR, will fall from 14.3 pediatricians per 100 000 children in 1996 to 12 by 2025. The Hispanic PCPR will fall from 16.9 in 1996 to 9.2 in 2025. The American Indian/Alaska Native PCPR will drop from 7.8 in 1996 to 6.5 by the year 2025. The PCPR specific to the Asian/Pacific Islander group will decline from 52.9 in 1996 to 26.1 in 2025. For whites, the PCPR will increase from 47.8 to 54.2 during this period. For 1996, each of the 5 PCPRs is significantly different from the comparison ratio. The same is true for 2025. For the time trend comparison (between 1996 and 2025), there is a significant difference for each ratio except for American Indian/Alaska Native.

CONCLUSION

The racial and ethnic makeup of the US child population is currently far more diverse than that of the pediatricians who provide their health care services. If child population demographic projections hold true, and no substantial shifts transpire in the composition of the pediatric workforce, the disparities will increase substantially by the year 2025.

General pediatricians, pediatric subspecialists, and pediatric primary care

OBJECTIVE

To assess the respective roles of general pediatricians and pediatric subspecialists in the provision of primary pediatric care.

DESIGN AND METHODS

A practice characteristics questionnaire that included questions about primary care was sent to a random sample of 1616 board-certified and board-eligible active Fellows of the American Academy of Pediatrics; 1145 (70.9%) responded. Analyses pertain to those pediatricians who provided ambulatory patient care and were not in graduate medical education training at the time of the survey. Respondents were divided into 2 groups for purposes of analysis: the 527 pediatricians whose practice was primarily in general pediatrics (defined as 80% of time spent in general pediatrics or any time spent in adolescent medicine) and the 213 pediatricians whose practice was subspecialty focused (all others). These groups were then further stratified according to whether they provided primary care. The resultant subgroups contained 518 general pediatricians and 98 subspecialists who provided primary care.

RESULTS

Among the entire sample, general pediatricians indicated that general pediatricians provide 93% of the primary care delivered by their practice and that pediatric subspecialists provide 2% of the primary care. In contrast, pediatric subspecialists reported that general pediatricians provide 53% of the primary care delivered by their practice and that subspecialists provide 32% of such care (P<.001). Among the subsample of pediatricians who provide primary care, general pediatricians reported delivering 88% of the primary care received by their patients and subspecialists reported delivering 74% of the primary care received by their patients (P<.001).

CONCLUSION

Perspectives on the degree to which pediatric subspecialists provide primary pediatric care vary depending on generalist vs subspecialist self-identification.

Health insurance and access to primary care for children

BACKGROUND

Numerous studies have demonstrated that insurance status influences the amount of ambulatory care received by children, but few have assessed the role of insurance as a determinant of children's access to primary care. We studied the effect of health insurance on children's access to primary care.

METHODS

We analyzed a sample of 49,367 children under 18 years of age from the 1993-1994 National Health Interview Survey, a nationwide household survey. The overall rate of response was 86.5 percent. The survey included questions on insurance coverage and access to primary care.

RESULTS

An estimated 13 percent of U.S. children did not have health insurance in 1993-1994. Uninsured children were less likely than insured children to have a usual source of care (75.9 percent vs. 96.2 percent, P<0.001). Among those with a usual source of care, uninsured children were more likely than insured children to have no regular physician (24.3 percent vs. 13.8 percent, P<0.001), to be without access to medical care after normal business hours (11.8 percent vs. 7.1 percent, P<0.001), and to have families that were dissatisfied with at least one aspect of their care (19.6 percent vs. 14.0 percent, P=0.01). Uninsured children were more likely than insured children to have gone without needed medical, dental, or other health care (22.2 percent vs. 6.1 percent, P<0.001). Uninsured children were also less likely than insured children to have had contact with a physician during the previous year (67.4 percent vs. 83.8 percent, P<0.001). All differences remained significant after we controlled for potential confounders using linear and logistic regression.

CONCLUSIONS

Among children, having health insurance is strongly associated with access to primary care. The new children's health insurance program enacted as part of the Balanced Budget Act of 1997 may substantially improve access to and use of primary care by children.

Patient-physician pairing: does racial and ethnic congruity influence selection of a regular physician?

Many public and private sector efforts are devoted toward increasing the training of physicians from under-represented minority groups, yet little has been documented regarding the association between physicians' racial backgrounds and the patient populations they serve. To address this question, we use 1987 National Medical Expenditure Survey to examine the impact of race/ethnicity on the matching between physician and patients. Our results show that minority patients are significantly more likely to report having a minority physician as their regular doctor. We estimate that minority patients are five times as likely as non-minorities to report that their regular physician is a member of a racial/ethnic minority. This effect is especially pronounced among Hispanics who identify a Hispanic physician as their regular provider 19 times more often than non-minorities. After controlling for other socioeconomic factors, both these figures remain significant, but drop by approximately one-half. These results support the notion that minority patients tend to see minority physicians at a disproportional rate independent of other socio-economic factors.

Hospital readmission with feeding-related problems after early postpartum discharge of normal newborns

CONTEXT

Increasingly short postpartum hospital stays in the United States precipitated a policy debate that culminated in passage of the Newborns' and Mothers' Health Protection Act of 1996. The debate occurred without population-based evidence for adverse health effects in newborns who are discharged early.

OBJECTIVE

To determine whether early postpartum hospital discharge of normal newborns increases their risk for hospital readmission with feeding-related problems.

DESIGN AND SETTING

Nested case-control analysis of 1991 to 1994 Wisconsin birth certificate and hospital discharge data.

SUBJECTS

A total of 210 readmitted case patients and 630 control subjects selected from a cohort of 120 290 normal newborns who weighed at least 2500 g, were delivered vaginally of mothers with uncomplicated medical and obstetrical histories, and were discharged from the hospital either early (day of life 1 or 2) or conventionally (day 3).

OUTCOME MEASURE

Readmission at age 4 to 28 days with discharge diagnoses indicating a primary feeding problem, secondary dehydration, or inadequate weight gain.

RESULTS

Early discharges increased 3-fold (reaching 521/1000 discharges) during the study period, but feeding-related readmissions (1.7/1000) remained stable. Most readmitted newborns (53.8%) were 4 to 7 days old, many (34.3%) had concurrent dehydration and jaundice, and 29% were admitted through emergency departments. Readmitted newborns were significantly (P<.05) more likely to have been breast-fed, firstborn, or preterm or to have mothers who were poorly educated (<12th grade), unmarried, or receiving Medicaid. Readmission was not associated with early discharge (adjusted odds ratio, 1.05; 95% confidence interval, 0.71-1.53).

CONCLUSION

Although several neonatal and maternal factors increase the risk that a normal newborn will be rehospitalized with a feeding-related problem, early discharge following an uncomplicated postpartum hospital stay appears to have little or no independent effect on this risk.

Tobacco and children. An economic evaluation of the medical effects of parental smoking

OBJECTIVE

To determine the economic influence of pediatric disease attributable to parental smoking.

DATA SOURCES

Computerized bibliographic databases were searched. Subject headings included asthma, burn, cost, low birth weight, otitis media, respiratory syncytial virus bronchiolitis, sudden infant death syndrome, and tobacco smoke pollution. The following constraints were applied to the published articles we studied: publication time, January 1980 through May 1996; age range of children studied, neonate to 18 years; and written in English. Articles used specifically as references for cost issues were limited to studies performed in the United States.

DATA EXTRACTION

This study is a literature synthesis, which uses as its primary source the results of previously published best estimates. This is not a meta-analysis of studies analyzing the relationships between childhood disease and smoking.

RESULTS

Using data for relative risk, prevalence, and cost of illness and death, we calculated the attributable risk fraction and corresponding direct medical expenditures and costs for loss of life. Costs are adjusted to 1993 dollars. Estimated annual excess cases of childhood illness and death attributable to parental smoking include low birth weight (46,000 cases, 2800 perinatal deaths), sudden infant death syndrome (2000 deaths), respiratory syncytial virus bronchiolitis (22,000 hospitalizations, 1100 deaths), acute otitis media (3.4 million outpatient visits), otitis media with effusion (110,000 tympanostomies), asthma (1.8 million outpatient visits, 14 deaths), and fire-related injuries (10,000 outpatient visits, 590 hospitalizations, and 250 deaths).

CONCLUSIONS

Parental smoking is an important preventable cause of morbidity and mortality among American children; it results in annual direct medical expenditures of $4.6 billion and loss of life costs of $8.2 billion. Additional efforts to reduce children's exposure to tobacco smoke are warranted.

State-to-state variations in newborn screening policies

BACKGROUND

Population-based newborn screening for genetic and metabolic disorders is standard practice in all states in the United States. Policies governing newborn screening are determined at the state level; however, and thus, a great degree of variability exists between states regarding many facets of such screening.

OBJECTIVE

To gather information relating to the processes, content, and outcomes of policy making affecting newborn screening programs across the United States.

METHODS

We surveyed the directors of newborn screening programs for each of the 50 states using a postal questionnaire. The questionnaire solicited information about the specific tests incorporated in each state's panel of screening tests and information pertaining to the policy-making processes by which decisions are reached regarding this testing.

RESULTS

Substantial variation exists across states regarding both the processes of policy formulation and the outcomes of decisions made about newborn screening. All states currently screen for phenylketonuria and congenital hypothyroidism. Extensive variation exists across states in testing for other disorders. The processes by which state policy makers arrive at decisions in this area are extremely diverse. Almost three fourths of the states have standing expert advisory bodies who issue recommendations regarding screening program modifications, but the authority granted to these panels varies substantially. Some regional cooperation in this area exists.

CONCLUSIONS

Further development of regional cooperation could offer some states greater efficiency in both laboratory testing and screening policy formulation. From the standpoint of an individual state. Wisconsin's approach to policy development in this area is described as a model worthy of consideration.

Maternal smoking and medical expenditures for childhood respiratory illness

OBJECTIVES

This study sought to assess the association between environmental tobacco smoke exposure from maternal smoking and health care expenditures for respiratory conditions among US children.

METHODS

Multivariate analysis of the 1987 National Medical Expenditure Survey was undertaken with a sample that included 2624 children 5 years of age and under.

RESULTS

After analysis that controlled for various sociodemographic factors associated with health care usage, respiratory-related health care expenditures among children whose mothers smoke were found to be significantly higher than those expenditures for children of nonsmoking mothers. Truncated regression techniques were used to estimate that maternal smoking was associated with increased health care expenditures averaging (in 1995 dollars) $120 per year for children aged 5 years and under and $175 per year for children aged 2 years and under. Our analysis indicates that passive smoking was associated with $661 million in annual medical expenditures in 1987, representing 19% of all expenditures for childhood respiratory conditions.

CONCLUSIONS

Maternal smoking is associated with significantly increased child health expenditures and contributes significantly to the overall cost of medical care.

Children's access to primary care: differences by race, income, and insurance status

OBJECTIVE

Congressional initiatives to reduce spending under major public programs designed to improve access to health care have brought renewed attention to the health care needs of traditionally disadvantaged populations. The objective of this study was to assess access to and use of primary care services for poor, minority, and uninsured children in the United States.

DESIGN AND SETTING

We analyzed data on 7578 1- to 17-year-old children of families responding to the 1987 National Medical Expenditure Survey, a nationally representative sample of families and children.

OUTCOME MEASURES

Adult respondents were asked to report on several measures of access and use of care for children in the household. These included the presence of a usual source of care and its characteristics (type of site, travel time, waiting time, after-hours care, and availability of a regular physician). We also examined the volume of physician contacts relative to the sample child's health status, the receipt of measles vaccinations, and whether children received care in response to selected symptoms of ill health. Results are presented for children generally and for four subgroups: poor children; minority children; uninsured children; and white, non-poor, insured children (the reference group).

RESULTS

Poor, minority, and uninsured children fared consistently worse than the children in the reference group on all indicators studied. For example, children in each of the three at-risk groups were twice as likely as the children in the reference group to lack usual sources of care, nearly twice as likely to wait 60 minutes or more at their sites of care, and used only about half as many physician services after adjusting for health status. Multivariate analyses revealed that poverty, minority status, and absence of insurance exert independent effects on access to and use of primary care.

CONCLUSIONS

The existence of substantial barriers to the access to and use of primary care for low-income, minority, and uninsured children is cause for significant concern, especially in an era of program cutbacks. New initiatives are needed to address both financial and non-financial barriers to the receipt of primary care for disenfranchised children.

Impact of parental smoking on the prevalence of wheezing respiratory illness in children

To quantitatively assess environmental tobacco smoke exposure from parental smoking as a risk factor for asthma or wheezing in childhood, and to derive estimates of excess asthma/wheezing lower respiratory tract illness cases attributable to this risk factor, a cross-sectional analysis of the 1987 National Medical Expenditure Survey (a national probability sample of the civilian, noninstitutionalized US population) was undertaken. The National Medical Expenditure Survey included 7,578 children and youth less than 18 years of age in a stratified cluster sampling of US households. After using logistic regression analysis to control for sex, race/ethnicity, region of residence, population density, poverty status, maternal educational level, family size, and father's current smoking status, children whose mothers smoked at the time of the survey were more likely than children of nonsmoking mothers to experience wheezing respiratory illness (odds ratio = 1.36, 95% confidence interval 1.14-1.62). The association was greatest among children less than 2 years of age. The authors' estimate of the attributable risk in the US population indicates that maternal smoking is responsible for approximately 380,000 excess cases of childhood asthma/wheezing lower respiratory tract illness or 7.5% of the total number of such symptomatic children.

Graduate medical education reform. Service provision transition costs

OBJECTIVE

To analyze the potential strategies and costs of house staff substitution under a reformed system of graduate medical education.

DESIGN

An economic model using two scenarios for substitution of house staff (residents and fellows): (1) a lower-cost model under which nonphysician providers assume many house staff responsibilities, but additional aspects of their workload are taken over by staff physicians, nurses, and ancillary personnel; and (2) a higher-cost traditional model that relies more heavily on staff physicians to replace house officers.

SETTING

US teaching hospitals.

MAIN OUTCOME MEASURES

Projected net substitution costs of house staff on a per full-time equivalent basis and aggregate national cost estimates of substitution.

RESULTS

Net annual house staff substitution costs were estimated to be $58,000 and $77,000 per replaced full-time equivalent house officer, respectively, under the two scenarios. Assuming elimination of approximately 23,200 house staff under a reformed system, total (net) substitution costs to teaching hospitals were estimated at approximately $1.4 billion to $1.8 billion nationally on an annual basis.

CONCLUSIONS

Graduate medical education reform, while likely to result in substantial long-term cost savings, will necessitate transitions in service provision that are likely to generate some new costs in the short term.

Health insurance status and ambulatory care for children

BACKGROUND

Many children in the United States lack health insurance. We tested the hypothesis that these children are less likely than children with insurance to visit a physician when they have specific conditions for which care is considered to be indicated.

METHODS

We examined the association between whether children were covered by health insurance and whether they received medical attention from a physician for pharyngitis, acute earache, recurrent ear infections, or asthma. Data were obtained on the subsample of 7578 children and adolescents 1 through 17 years of age who were included in the 1987 National Medical Expenditures Survey, a national probability sample of the civilian, noninstitutionalized population.

RESULTS

Uninsured children were more likely than children with health insurance to receive no care from a physician for all four conditions (unadjusted odds ratios, 2.38 for pharyngitis; 2.04 for acute earache; 2.84 for recurrent ear infections; and 1.87 for asthma). Multiple logistic-regression analysis was subsequently used to control for age, sex, family size, race or ethnic group, region of the country, place of residence (rural vs. urban), and household income. After adjustment for these factors, uninsured children remained significantly more likely than insured children to go without a visit to a physician for pharyngitis (adjusted odds ratio, 1.72; 95 percent confidence interval, 1.11 to 2.68), acute earache (1.85; 95 percent confidence interval, 1.15 to 2.99), recurrent ear infections (2.12; 95 percent confidence interval, 1.28 to 3.51), and asthma (1.72; 95 percent confidence interval, 1.05 to 2.83).

CONCLUSIONS

As compared with children with health insurance, children who lack health insurance are less likely to receive medical care from a physician when it seems reasonably indicated and are therefore at risk for substantial avoidable morbidity.

Yersinia enterocolitica infection in a patient with sickle cell disease after exposure to chitterlings

PURPOSE

We describe certain clinical, epidemiologic, and host-susceptibility features of Yersinia enterocolitica infection in the context of a patient with underlying risk factors.

PATIENTS AND METHODS

A 10-year-old black girl with sickle cell disease receiving chelation therapy for iron overload resulting from chronic transfusion therapy was admitted with acute abdominal pain and fever.

RESULTS

Upon hospital admission, differential diagnoses included enterocolitis, appendicitis, and vasoocclusive crisis. On the 6th hospital day, the patient's stool culture became positive for Y. enterocolitica. Household exposure to raw pork intestines (chitterlings) was the presumed source of the infection. Deferoxamine therapy was withheld, and antibiotic therapy was administered with subsequent clinical improvement.

CONCLUSIONS

Y. enterocolitica infection should be considered as a cause of abdominal pain mimicking appendicitis in patients with underlying risk factors (including certain sickle cell patients). History of exposure to raw or undercooked pork products and appropriate cultures should be obtained. Deferoxamine therapy should be withheld in iron-overloaded patients presenting with such symptoms because deferoxamine and iron overload constitute independent risk factors for Yersinia infection. Such patients should be advised to avoid potential exposures to this pathogen.

Prevalence and impact of multiple childhood chronic illnesses

OBJECTIVE

To determine the prevalence and impact of multiple chronic conditions on children's health status and utilization of health services.

DESIGN

Analysis of the 1988 National Health Interview Survey on Child Health.

SETTING

Nationally representative sample of the U.S. civilian, noninstitutionalized population.

PARTICIPANTS

A total of 17,710 children less than 18 years of age selected in a stratified cluster sampling of U.S. households.

INTERVENTION

None.

RESULTS

We estimated that fewer than 5% of children have multiple (two or more) chronic conditions and that less than 1% of children had three or more such conditions. However, despite this low overall prevalence, some notable features of multiple chronic conditions stand out. Many of the most prevalent condition-pairs were allergy related, and the rates of co-occurrence of these disorders were generally higher than would be predicted on the basis of prevalence rates for the individual conditions. Children with multiple chronic conditions had more mental and physical health problems and used substantially more health services than other children. For example, the prevalence of developmental delay, learning disabilities, and emotional and behavioral problems increased sharply with the number of chronic conditions reported. Notable deterioration in such health status measures as days in bed, school absences, and activity limitation was also observed with increasing numbers of chronic conditions. Similarly, utilization of hospital and physician services increased in tandem with increasing numbers of chronic conditions.

CONCLUSIONS

Children who have multiple conditions of a chronic nature, even if few in number, have increased morbidity across a variety of measures.

Hepatitis B virus transmission between children in day care

We investigated two situations involving hepatitis B virus exposure among children in day care. In the first a 4-year-old boy who attended a day care center developed acute hepatitis B; another child at the center, who had a history of aggressive behavior (biting/scratching), was subsequently found to be a hepatitis B carrier. No other source of infection among family and other contacts was identified and no other persons at the center became infected. In the second situation a 4-year-old boy with frequently bleeding eczematous lesions was discovered to be a hepatitis B carrier after having attended a day care center for 17 months. Testing of contacts at the center revealed no transmission to other children or staff (representing 887 person months of exposure). Nationwide surveillance data showed that for the period 1983 to 1987, 161 children 1 to 4 years of age were reported with acute hepatitis B. After children with known hepatitis B risk factors were excluded, 25% (7 of 28) of children with known day care status were reported as day care attendees, a percentage comparable to national estimates of day care attendance by this age group. This is the first reported case of hepatitis B virus transmission between children in day care in the United States. Although it appears that day care transmission of hepatitis B is infrequent, further studies are needed to define the risk more accurately.