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January 5, 2020

Teenage students and their parents often don’t know much about Epstein-Barr Virus infections. But mention the word “mono” and you’ll get an immediate reaction: “that’s bad stuff; something to stay away from.” Exactly. At the University of Minnesota Epstein-Barr Diseases Research Program, our prospective studies have shown that about 50 percent of freshmen at the universities of Minnesota and Iowa are naïve to EBV at the beginning of their first semester, however, 25 percent of them will acquire a primary EBV infection before the end of their second semester. The vast majority of these infections manifest as mono with a median duration of 17 days. For college students, mono is clearly an illness worth preventing. And this is, in part, why we’ve spent nearly the past two decades developing a prophylactic EBV vaccine.

About the vaccine

EBV initiates infection of B lymphocytes by binding its major surface glycoprotein (gp350) to CD21 on the B cell surface. Antibody against gp350 effectively blocks infection of B cells by EBV. Therefore, we have selected EBV gp350 to be the backbone of our vaccine. Because EBV is the first recognized human cancer virus, a whole live virus vaccine is not feasible. Thus, our vaccine is only a piece of the virus, which will be adjuvanted with a derivative of monophosphoryl lipid A. A similar vaccine was safe and prevented mono among Belgian college students, so our vaccine already has a positive track record.

Should this be a pediatric vaccine?

We think so, because a prophylactic vaccine needs to be given before primary infection.  Research we’ve done both locally in collaboration with HealthPartners colleagues and nationally using samples from the National Health and Nutrition Examination Survey indicates that an EBV vaccine should be given about the time of school entry in order to protect the majority of vaccinees from getting mono. The high incidence of mono among college freshmen makes them ideal participants for the initial clinical trials, but children would be next in line.

Could EBV vaccine prevent more than mono?

Yes. EBV is the cause of a number of human cancers including Hodgkin’s lymphoma, lymphomas after organ or cell transplantation, gastric adenocarcinoma, and nasopharyngeal carcinoma. EBV is inextricably linked to autoimmune diseases, especially multiple sclerosis, but also lupus erythematosus, rheumatoid arthritis, and, recently, psoriasis. Since a history of mono is a risk factor for Hodgkin’s lymphoma and multiple sclerosis, and an EBV vaccine has been shown to prevent mono, it is logical to predict that a prophylactic EBV vaccine could prevent or reduce the incidence of all of the above-mentioned cancers and autoimmune disorders.

Timelines

The development of a vaccine for human use is a slow process.  We began this odyssey in 2002 and it’s still a work in progress. But there has been progress. In 2017, we obtained materials to create our candidate vaccine from an industrial partner. Soluble gp350 has been produced in the University of Minnesota Molecular and Cellular Therapeutics Laboratory and is ready for purification, after which preclinical testing can begin. We don’t want to overpromise, but a likely scenario is to complete purification and preclinical testing by summer 2020, and then apply to the FDA for an investigational new drug (IND) status by the end of 2020. If an IND is granted, we would launch clinical trials in summer 2021.


About the Author

Henry “Hank” Balfour, MD, is a professor of Pediatrics, and Laboratory Medicine and Pathology at the University of Minnesota Medical School where he has been researching the prevention and treatment of herpesvirus infections for the past 50 years.

When I returned from the American Academy of Pediatrics National Conference & Exhibition (NCE) that was held in New Orleans this year, I felt energized and rejuvenated after listening to the many speakers and mingling with pediatricians from across the United States and other countries. It is abundantly clear that children all over the world are faced with similar challenges including poverty, barriers to access, disparities and trauma to name a few.

I came away from the conference with many useful notes and pieces of information. I am going to share a few of the pearls that I took away from the NCE. I hope you find them interesting and helpful.

Lip tie and Ankyloglossia

  • There was no such thing as upper lip tie until 2012.
  • 85 percent of people have lip tie
  • There is inadequate research to support routine frenotomy for posterior ankyloglossia or upper lip tie for breastfeeding problems.

Asthma

  • 50 percent of children have uncontrolled asthma
  • 30-70 percent report poor adherence
  • Inhaler technique should be reviewed at every visit
  • A spacer device can be purchased from Amazon for less than $20. Often the insurance copay is $50.

Dr. Peter Hotez, a pediatrician and a scientist, presented about the anti-vaccine movement and discussed ways to address the concerns of vaccine-hesitant parents. It struck a chord when he stated, “We have to build into our science training how to engage the public. This used to be thought of as grandstanding.”

Implicit Bias:

  • Going to medical school does not make you immune to bias.
  • Burnout can increase your bias.
  • The good news is that bias is modifiable.

You can help build resilience in families dealing with chronic illness. Look the parent/caretaker in the eye and ask, “how are you doing?” Then listen attentively.  This seemingly small thing can make a difference in building a family’s resilience.

A good website to check out for gun safety resources is www.besmartforkids.org. It offers a framework to help parents and adults normalize conversations about gun safety and take responsible actions that can prevent child gun deaths and injuries.

Overcoming the Belief in Human Hierarchy

The speaker Gail Christopher stated, “To be biased does not make us racist – it makes us human.” Narrative change is the key. We must change the narrative to achieve racial healing. “Our greatest task is to learn to see ourselves in the face of others.”–Albert Einstein.

Suicide prevention:

  • The suicide rate for 10-14 year olds has doubled in the last decade.
  • Suicide isn’t a single cause-effect phenomenon.
  • Putting caring contacts in place has some of the most robust effectiveness in suicide prevention.

Josh Shipp spoke about his childhood in numerous foster care placements and how he started acting out so that he would get kicked out of each home as quickly as possible. “Every kid is one choice away from being a statistic,” said Shipp. “Every kid is one caring adult away from being a success story.” He shared that it is important for the caring adult to be tough and tender.  The child that is struggling must develop the intrinsic motivation to change their own life.

Child Health in the Warming World:

  • The climate crisis is a health crisis.
  • Addressing climate change is the greatest health opportunity.
  • We, as pediatricians, are taking care of children who are on the front lines of this climate problem.  “All we have to do to end their world is nothing,” stated Dr. Debra Hendrickson, an environmental analyst who later became a pediatrician.

There is so much to think about – it can easily become overwhelming. So, as we continue to take the best care of children and families that we can, please support each other, be kind to one another and know that the work that we do is a calling and a privilege.

MNAAP has more than 1,000 members with careers that span differing lengths, specialties and interests. The Member Spotlight offers you a chance to meet a fellow MNAAP member and learn a little bit more about them. Dr. Tom Scott is a familiar face to many MNAAP members, and graciously agreed to answer Minnesota Pediatrician’s questions for this issue’s Member Spotlight.


You have been a long-standing member of MNAAP. What have been the most rewarding aspects of your participation in our chapter?

I worked clinically for 26 years as a general pediatrician and developmental-behavioral pediatric (DBP) consultant at HealthPartners, and then for eight years at the Alexander Center of ParkNicollet as a DBP specialist on interdisciplinary teams. While in practice, I enjoyed the great opportunity of connecting with other pediatricians with advocacy interests through the MNAAP policy work group.

Learning from mentors such as Drs. Mike Severson and Chuck Oberg helped me grow in this very significant aspect of pediatric care. When bullying became more notable as a health issue, I was very appreciative of the chapter’s support while on Governor Dayton’s Task Force on the Prevention of School Bullying. I had been concerned about the vulnerability of children with autism and LGBTQ youth in my practice who were being bullied.   

Can you tell me about your shift from pediatric practice settings in the community to teaching at the University of Minnesota later in your career?

For the last 10 years, I have been at the University of Minnesota (UMN) doing curriculum development and teaching part-time in the pediatric department. I directed the residency rotation in developmental-behavioral pediatrics for five years and continue co-teaching a monthly seminar for residents on historical trauma and racism. Being part of the UMN pediatric department has been a wonderfully rich experience.

While working at UMN, I was able to bring highly skilled pediatricians in the community to be part of our teaching program. We also developed pediatrician/psychologist teaching teams that reflected our understanding of clinical challenges and the need for collaborative approaches to pediatric services. Similarly, our recognition of disparities and social determinants of health led us to connect with programs such as Simpson Housing Services and the Minnesota Organization on Fetal Alcohol Syndrome (MOFAS), as settings for resident learning.

I understand that you retired from the UMN about a year ago.  How are you staying connected with the pediatric community?

In addition to my monthly seminar teaching with residents at UMN, I enjoy staying involved in MNAAP. For the past two years, Dr. Nate Chomilo and I have been MNAAP “Early Childhood Champions” in Minnesota and representatives to the AAP. Nate and I work with a very active early childhood caucus of committed pediatrician advocates. My particular focus is on prenatal to age three, a time when 80 percent of brain growth happens. Last year, the AAP State Advocacy Office helped us write an EC P3 policy development guide that is based on Minnesota data and AAP Policy Statements. You can find these under the “Resources” section of the Poverty and Disparities page on MNAAP.org.

I have recently joined Dr. Rachel Tellez as co-chair of the MNAAP Poverty and Disparities Work Group. We are developing a series of exciting and challenging initiatives including the Impact of Racism on Child Health, Food Insecurity, Oral Health, and Immigrant Health.

What kinds of hobbies or activities do you enjoy?

I especially like being up at our family cabin in northern Minnesota with my grandkids and getting out on the water. At home, biking, being outside, and walking around the city lakes are my favorites. I like to travel whenever I can, often to the east coast or to warmer climes to spend time with friends. I love taking in classical music, and dance wherever I am and like to read along the way.


Editor’s Note: Dr. Scott authored an informative look at developmental-behavioral pediatrics as a contributor in a past issue of Minnesota Pediatrician.To access the article, visit www.mnaap.org/what-is-developmental-behavioral-health-pediatrics/.

With the 2020 legislative session beginning on Feb. 11, 2020, the MNAAP took the next steps to pursue our legislative agenda when the Board of Directors selected the chapter’s 2020 legislative priorities. The chapter will focus on increasing immunization rates and enacting common-sense provisions to reduce firearm violence. The two priorities were identified through a MNAAP policy roundtable discussion with members after reviewing the results of the all-member survey, and were affirmed by the MNAAP Board of Directors.

Recognizing the significant risk for outbreaks of vaccine-preventable disease, the MNAAP has long argued that Minnesota’s vaccine requirement for school-aged children – among the weakest in the country – needs reform. Minnesota was the scene of a major measles outbreak in 2017, and even larger outbreaks occurred earlier this year in New York and elsewhere. Many states – California, New York, and Maine notably – have strengthened their childhood immunization requirements in the wake of these threats to public health, and Minnesota would be wise to follow their lead.

Make no mistake, fixing Minnesota’s weak vaccine law will be an uphill battle given the influence of anti-vaccine activists and legislators.  The anti-vaccine community is very well organized, and they routinely fill legislators’ inboxes with dozens, even hundreds, of emails.  It will take the action of pediatricians, other physicians, health advocates, and parents from across the state voicing their support of strengthened vaccine requirements for us to be successful.

The MNAAP has once again chosen to tackle firearm violence in the upcoming session. Specifically, the chapter will partner with legislative champions and allied groups to extend background checks to all sales and transfers of firearms, including at gun shows and private sales. In addition, the MNAAP will lobby for passage of a “red flag law” to allow law enforcement to seize firearms from those individuals who may be a danger to themselves or others. Recent legislative sessions have seen chapter leaders testify in support of these common-sense proposals, and our advocacy will continue.

While increasing immunization rates and reducing firearm violence are the chapter’s identified legislative priorities, the MNAAP will be closely tracking dozens of other issues. Efforts to bar the use of conversion therapy for minors, promote health equity, and eliminate teen access to tobacco and e-cigarettes will remain on the chapter’s radar. Each legislative session always brings surprising issues that require the MNAAP’s involvement. In 2018, for example, the chapter was forced to quickly mobilize to oppose efforts to weaken safe sleep requirements in child care settings.

Be sure to mark your calendar for the 2020 Pediatricians’ Day at the Capitol set for Monday, March 23.  The MNAAP’s single biggest advocacy event, Pediatricians’ Day at the Capitol is always a terrific day of advocacy and energy.  This day is critically important to our advocacy efforts.  Visit www.mnaap.org/day-at-the-capitol/ to register and make plans to join us!


Written by Eric Dick, MNAAP lobbyist

December 27, 2019

Join us at the Celebrate Immunization Rally at the Capitol!

Tuesday, February 18, 2020 (from 11-11:30 a.m.) will be the state’s biggest show of support for immunizations and their power to protect every Minnesota community from vaccine-preventable diseases. Stand alongside parents and other medical providers at the Minnesota State Capitol rotunda for the Celebrate Immunization Rally!

MNAAP is a partner in this event, and we want our members to have a strong presence in support of immunization. Let us know if you’re interested in carpooling with other members. Strengthening immunization laws continues to be a MNAAP policy priority, and a strong presence at the Capitol helps underscore the importance of this effort.

Register now!

Organized by Minnesota Immunization Coalition with Voices for Vaccines, an internationally recognized parent-driven vaccine advocacy group.

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