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Infection, vaccination, and childhood arterial ischemic stroke: Results of the VIPS study
Heather J Fullerton1, Nancy K Hills2, Mitchell S V Elkind2
1From the Departments of Neurology (H.J.F., N.K.H., A.J.B.), Pediatrics (H.J.F., C.A.G., A.J.B.), Biostatistics and Epidemiology (N.K.H.), and Radiology (A.J.B.), University of California San Francisco; the Departments of Neurology and Epidemiology (M.S.V.E.), Columbia University College of Physicians and Surgeons and Mailman School of Public Health, New York, NY; the Departments of Pediatrics and Neurology and Neurotherapeutics (M.M.D.), UT Southwestern Medical Center, Dallas, TX; the Department of Radiology (M.W.), Stanford University, Palo Alto, CA; the Division of Communicable Disease Control (C.A.G.), Center for Infectious Diseases, California Department of Public Health, Richmond; the Departments of Pediatrics and Neurosciences (M.T.), University of the Philippines-Philippine General Hospital, Manila, Philippines; the Departments of Neurology, Psychiatry, and Radiology (M.J.R.), Boston Children's Hospital, MA; the Pediatric Emergency Department (L.T.), Robert Debré Hospital, Paris Diderot University, Paris, France; and the Department of Neurology (G.A.d.), Hospital for Sick Children, Toronto, Canada. Heather.Fullerton@ucsf.edu.
Insights
Infections may trigger arterial ischemic stroke (AIS) in children, increasing risk significantly. Routine childhood vaccinations appear protective against AIS, suggesting infection prevention strategies could reduce stroke incidence.
Area of Science:
- Pediatric Neurology
- Infectious Diseases
- Public Health
Background:
- Infections are known triggers for arterial ischemic stroke (AIS) in adults.
- Childhood AIS is a significant concern, with infections being a common factor.
Purpose of the Study:
- To investigate if infections transiently increase AIS risk in children.
- To determine if childhood vaccinations are protective against AIS.
Main Methods:
- International case-control study (Vascular Effects of Infection in Pediatric Stroke).
- Prospective enrollment of 355 AIS cases and 354 controls (29 days–18 years).
- Parental interviews and chart reviews to assess infection and vaccination history.
Main Results:
- Infection in the week prior to stroke increased AIS risk 6.3-fold (p < 0.0001).
- Undervaccination was associated with significantly higher stroke risk (OR 8.2, p = 0.0004).
- Independent risk factors included prior infection, undervaccination, Black race, and rural residence.
Conclusions:
- Infections may serve as a trigger for AIS in pediatric populations.
- Routine vaccinations appear to offer protection against childhood AIS.
- Reducing infection spread could be a key strategy for pediatric stroke prevention.
Objectives:
Minor infection can trigger adult arterial ischemic stroke (AIS) and is common in childhood. We tested the hypotheses that infection transiently increases risk of AIS in children, regardless of stroke subtype, while vaccination against infection is protective.
Methods:
The Vascular Effects of Infection in Pediatric Stroke study is an international case-control study that prospectively enrolled 355 centrally confirmed cases of AIS (29 days-18 years old) and 354 stroke-free controls. To determine prior exposure to infections and vaccines, we conducted parental interviews and chart review.
Results:
Median (interquartile range) age was 7.6 years for cases and 9.3 for controls (p = 0.44). Infection in the week prior to stroke, or interview date for controls, was reported in 18% of cases, vs 3% of controls, conferring a 6.3-fold increased risk of AIS (p < 0.0001); upper respiratory infections were most common. Prevalence of preceding infection was similar across stroke subtypes: arteriopathic, cardioembolic, and idiopathic. Use of vasoactive cold medications was similarly low in both groups. Children with some/few/no routine vaccinations were at higher stroke risk than those receiving all or most (odds ratio [OR] 7.3, p = 0.0002). In an age-adjusted multivariate logistic regression model, independent risk factors for AIS included infection in the prior week (OR 6.3, p < 0.0001), undervaccination (OR 8.2, p = 0.0004), black race (compared to white; OR 1.9, p = 0.009), and rural residence (compared to urban; OR 3.0, p = 0.0003).
Conclusions:
Infection may act as a trigger for childhood AIS, while routine vaccinations appear protective. Hence, efforts to reduce the spread of common infections might help prevent stroke in children.
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