Miriam E. Tucker

Adult immunization rates in the United States are improving but very slowly, according to new data from the Centers for Disease Control and Prevention released on Nov. 17.

Overall, the 2009 National Health Interview Survey of 88,446 adults showed that adult immunization rates for influenza, hepatitis B, pertussis, and shingles increased by small proportions, compared with the previous year, while pneumococcal disease coverage dropped slightly. Moreover, large racial disparities persisted for influenza immunization, with lower proportions of African Americans and Hispanics receiving the vaccine than whites.

"We have wonderful vaccination rates in young children ... but there are lower vaccination rates in adults, and they show us that maybe we're starting to take vaccines and immunity for granted. This is one area where we cannot rest on our laurels. Our accomplishments will be undone if we don’t maintain our immunity as adults," Dr. Susan J. Rehm, medical director of the National Foundation for Infectious Diseases (NFID), said in a press briefing.

The NFID, which cosponsored the briefing with the CDC, also released the findings from its survey of 300 primary care physicians and 1,013 American consumers aged 18 years and older, which showed a distinct communication disconnect: Whereas 90% of the physicians said they discuss vaccines with their patients, 47% of the patients couldn't recall ever discussing vaccines other than influenza with their doctors, and one-fifth couldn’t recall discussing any vaccines.

However, nearly 9 in 10 patients said that a strong recommendation from a physician would be a very likely motivator for them to get vaccinated. "Overall I think these findings are in a way encouraging. Although we have this disconnect, we have a solvable problem, and that is communication. Patients need to hear the recommendation from their provider, and it needs to be clear," said Dr. Rehm of the Cleveland Clinic.

She added that because adults typically visit the doctor for an acute problem and not for routine medical care, "every adult visit needs to be an immunization visit."

Dr. Melinda Wharton, deputy director of the CDC’s National Center for Immunization and Respiratory Diseases, reviewed the data from the 2009 NHIS. For influenza vaccine, there was an overall 2.3 percentage point increase among adults aged 19-49 years during the 2008-2009 season, compared with 2007-2008. While the increase was even greater for African Americans, 3.6 percentage points, their overall influenza immunization rate was just 16.5%, compared with 21.6% among whites. The percentage among Hispanics in that age group was 14.5%, up by just 1.5 percentage points.

For ever-receipt of pneumococcal vaccine among those for whom it is recommended, coverage among adults aged 19-64 years in 2009 was 17.5%, a drop of 7.4 percentage points since 2008. This is likely due in part to the recent addition of smokers and asthma patients to the high-risk list, Dr. Wharton said, noting that coverage among adults aged 65 years and older remained stable, at about 61%.

Immunization against hepatitis B among those at risk increased to the greatest degree among African Americans, rose by 13.6 percentage points to 43.6%, similar to the 43.2% among whites. Herpes zoster vaccine, on the other hand, increased by just 3.3 percentage points, from 6.7% of adults aged 60 years and older in 2008 to 10.0% in 2009. In 2009, the proportion of women aged 19-26 years who received human papillomavirus vaccination was just 17.1%, up by 6.6 percentage points from 10.5% in 2008.

Data for pertussis – which is receiving increased attention now because of the California outbreak – is reported via tetanus coverage. In 2005, the CDC recommended that the then-newly licensed adult/adolescent formula tetanus-diphtheria-pertussis vaccine (Tdap) replace a single dose of Td vaccine for individuals aged 10-64 years. Of adults aged 19-64 years who received a tetanus vaccine since 2005 and knew which kind of vaccine they had received, only 50.8% reported receiving Tdap.

The NHIS data also included health care provider immunization rates, which showed an overall 7.1 percentage point increase in influenza immunization from 2007 to 2008 to 52.9% in 2008-2009, a 1.6 percentage point increase in the proportion of tetanus vaccination during 2005-2009 given as Tdap, to 58.3% in 2009, and a slight 0.5 percentage point rise in ever-receipt of three doses of hepatitis B vaccine, reaching 64.7% in 2009.

Dr. Rehm noted that 57% of physicians reported in the NFID survey that they didn’t have adequate time to discuss vaccination during hurried office visits. But, she said, "The immunization discussion doesn’t need to be long. It needs to be concise and clear. When I talk with my patients, I don’t say ‘I think you should consider the vaccine,’ and so on. I simply say I recommend that you receive this vaccine.’ Data show that patients are quite receptive to that, and look to their providers for that recommendation."

The NFID has a new dedicated adult vaccination Web site for patients, www.adultvaccination.com.

Dr. Rehm has served as a speaker for Sanofi-Pasteur and Genentech, as a speaker and principal adviser for a research study for Cubist Pharmaceuticals Inc., and as an advisory committee member for Pfizer Inc. and Merck & Co. Inc. Dr. Wharton is an employee of CDC with no financial disclosures.

Adult immunization rates in the United States are improving but very slowly, according to new data from the Centers for Disease Control and Prevention released on Nov. 17.

Overall, the 2009 National Health Interview Survey of 88,446 adults showed that adult immunization rates for influenza, hepatitis B, pertussis, and shingles increased by small proportions, compared with the previous year, while pneumococcal disease coverage dropped slightly. Moreover, large racial disparities persisted for influenza immunization, with lower proportions of African Americans and Hispanics receiving the vaccine than whites.

"We have wonderful vaccination rates in young children ... but there are lower vaccination rates in adults, and they show us that maybe we're starting to take vaccines and immunity for granted. This is one area where we cannot rest on our laurels. Our accomplishments will be undone if we don’t maintain our immunity as adults," Dr. Susan J. Rehm, medical director of the National Foundation for Infectious Diseases (NFID), said in a press briefing.

The NFID, which cosponsored the briefing with the CDC, also released the findings from its survey of 300 primary care physicians and 1,013 American consumers aged 18 years and older, which showed a distinct communication disconnect: Whereas 90% of the physicians said they discuss vaccines with their patients, 47% of the patients couldn't recall ever discussing vaccines other than influenza with their doctors, and one-fifth couldn’t recall discussing any vaccines.

However, nearly 9 in 10 patients said that a strong recommendation from a physician would be a very likely motivator for them to get vaccinated. "Overall I think these findings are in a way encouraging. Although we have this disconnect, we have a solvable problem, and that is communication. Patients need to hear the recommendation from their provider, and it needs to be clear," said Dr. Rehm of the Cleveland Clinic.

She added that because adults typically visit the doctor for an acute problem and not for routine medical care, "every adult visit needs to be an immunization visit."

Dr. Melinda Wharton, deputy director of the CDC’s National Center for Immunization and Respiratory Diseases, reviewed the data from the 2009 NHIS. For influenza vaccine, there was an overall 2.3 percentage point increase among adults aged 19-49 years during the 2008-2009 season, compared with 2007-2008. While the increase was even greater for African Americans, 3.6 percentage points, their overall influenza immunization rate was just 16.5%, compared with 21.6% among whites. The percentage among Hispanics in that age group was 14.5%, up by just 1.5 percentage points.

For ever-receipt of pneumococcal vaccine among those for whom it is recommended, coverage among adults aged 19-64 years in 2009 was 17.5%, a drop of 7.4 percentage points since 2008. This is likely due in part to the recent addition of smokers and asthma patients to the high-risk list, Dr. Wharton said, noting that coverage among adults aged 65 years and older remained stable, at about 61%.

Immunization against hepatitis B among those at risk increased to the greatest degree among African Americans, rose by 13.6 percentage points to 43.6%, similar to the 43.2% among whites. Herpes zoster vaccine, on the other hand, increased by just 3.3 percentage points, from 6.7% of adults aged 60 years and older in 2008 to 10.0% in 2009. In 2009, the proportion of women aged 19-26 years who received human papillomavirus vaccination was just 17.1%, up by 6.6 percentage points from 10.5% in 2008.

Data for pertussis – which is receiving increased attention now because of the California outbreak – is reported via tetanus coverage. In 2005, the CDC recommended that the then-newly licensed adult/adolescent formula tetanus-diphtheria-pertussis vaccine (Tdap) replace a single dose of Td vaccine for individuals aged 10-64 years. Of adults aged 19-64 years who received a tetanus vaccine since 2005 and knew which kind of vaccine they had received, only 50.8% reported receiving Tdap.

The NHIS data also included health care provider immunization rates, which showed an overall 7.1 percentage point increase in influenza immunization from 2007 to 2008 to 52.9% in 2008-2009, a 1.6 percentage point increase in the proportion of tetanus vaccination during 2005-2009 given as Tdap, to 58.3% in 2009, and a slight 0.5 percentage point rise in ever-receipt of three doses of hepatitis B vaccine, reaching 64.7% in 2009.

Dr. Rehm noted that 57% of physicians reported in the NFID survey that they didn’t have adequate time to discuss vaccination during hurried office visits. But, she said, "The immunization discussion doesn’t need to be long. It needs to be concise and clear. When I talk with my patients, I don’t say ‘I think you should consider the vaccine,’ and so on. I simply say I recommend that you receive this vaccine.’ Data show that patients are quite receptive to that, and look to their providers for that recommendation."

The NFID has a new dedicated adult vaccination Web site for patients, www.adultvaccination.com.

Dr. Rehm has served as a speaker for Sanofi-Pasteur and Genentech, as a speaker and principal adviser for a research study for Cubist Pharmaceuticals Inc., and as an advisory committee member for Pfizer Inc. and Merck & Co. Inc. Dr. Wharton is an employee of CDC with no financial disclosures.

Adult immunization rates in the United States are improving but very slowly, according to new data from the Centers for Disease Control and Prevention released on Nov. 17.

Overall, the 2009 National Health Interview Survey of 88,446 adults showed that adult immunization rates for influenza, hepatitis B, pertussis, and shingles increased by small proportions, compared with the previous year, while pneumococcal disease coverage dropped slightly. Moreover, large racial disparities persisted for influenza immunization, with lower proportions of African Americans and Hispanics receiving the vaccine than whites.

"We have wonderful vaccination rates in young children ... but there are lower vaccination rates in adults, and they show us that maybe we're starting to take vaccines and immunity for granted. This is one area where we cannot rest on our laurels. Our accomplishments will be undone if we don’t maintain our immunity as adults," Dr. Susan J. Rehm, medical director of the National Foundation for Infectious Diseases (NFID), said in a press briefing.

The NFID, which cosponsored the briefing with the CDC, also released the findings from its survey of 300 primary care physicians and 1,013 American consumers aged 18 years and older, which showed a distinct communication disconnect: Whereas 90% of the physicians said they discuss vaccines with their patients, 47% of the patients couldn't recall ever discussing vaccines other than influenza with their doctors, and one-fifth couldn’t recall discussing any vaccines.

However, nearly 9 in 10 patients said that a strong recommendation from a physician would be a very likely motivator for them to get vaccinated. "Overall I think these findings are in a way encouraging. Although we have this disconnect, we have a solvable problem, and that is communication. Patients need to hear the recommendation from their provider, and it needs to be clear," said Dr. Rehm of the Cleveland Clinic.

She added that because adults typically visit the doctor for an acute problem and not for routine medical care, "every adult visit needs to be an immunization visit."

Dr. Melinda Wharton, deputy director of the CDC’s National Center for Immunization and Respiratory Diseases, reviewed the data from the 2009 NHIS. For influenza vaccine, there was an overall 2.3 percentage point increase among adults aged 19-49 years during the 2008-2009 season, compared with 2007-2008. While the increase was even greater for African Americans, 3.6 percentage points, their overall influenza immunization rate was just 16.5%, compared with 21.6% among whites. The percentage among Hispanics in that age group was 14.5%, up by just 1.5 percentage points.

For ever-receipt of pneumococcal vaccine among those for whom it is recommended, coverage among adults aged 19-64 years in 2009 was 17.5%, a drop of 7.4 percentage points since 2008. This is likely due in part to the recent addition of smokers and asthma patients to the high-risk list, Dr. Wharton said, noting that coverage among adults aged 65 years and older remained stable, at about 61%.

Immunization against hepatitis B among those at risk increased to the greatest degree among African Americans, rose by 13.6 percentage points to 43.6%, similar to the 43.2% among whites. Herpes zoster vaccine, on the other hand, increased by just 3.3 percentage points, from 6.7% of adults aged 60 years and older in 2008 to 10.0% in 2009. In 2009, the proportion of women aged 19-26 years who received human papillomavirus vaccination was just 17.1%, up by 6.6 percentage points from 10.5% in 2008.

Data for pertussis – which is receiving increased attention now because of the California outbreak – is reported via tetanus coverage. In 2005, the CDC recommended that the then-newly licensed adult/adolescent formula tetanus-diphtheria-pertussis vaccine (Tdap) replace a single dose of Td vaccine for individuals aged 10-64 years. Of adults aged 19-64 years who received a tetanus vaccine since 2005 and knew which kind of vaccine they had received, only 50.8% reported receiving Tdap.

The NHIS data also included health care provider immunization rates, which showed an overall 7.1 percentage point increase in influenza immunization from 2007 to 2008 to 52.9% in 2008-2009, a 1.6 percentage point increase in the proportion of tetanus vaccination during 2005-2009 given as Tdap, to 58.3% in 2009, and a slight 0.5 percentage point rise in ever-receipt of three doses of hepatitis B vaccine, reaching 64.7% in 2009.

Dr. Rehm noted that 57% of physicians reported in the NFID survey that they didn’t have adequate time to discuss vaccination during hurried office visits. But, she said, "The immunization discussion doesn’t need to be long. It needs to be concise and clear. When I talk with my patients, I don’t say ‘I think you should consider the vaccine,’ and so on. I simply say I recommend that you receive this vaccine.’ Data show that patients are quite receptive to that, and look to their providers for that recommendation."

The NFID has a new dedicated adult vaccination Web site for patients, www.adultvaccination.com.

Dr. Rehm has served as a speaker for Sanofi-Pasteur and Genentech, as a speaker and principal adviser for a research study for Cubist Pharmaceuticals Inc., and as an advisory committee member for Pfizer Inc. and Merck & Co. Inc. Dr. Wharton is an employee of CDC with no financial disclosures.

Adult immunization rates in the United States are improving but very slowly, according to new data from the Centers for Disease Control and Prevention released on Nov. 17.

Photo credit: U.S. Navy photo by Mass Communication Specialist 1st Class Todd Hack.

Overall, the 2009 National Health Interview Survey of 88,446 adults showed that adult immunization rates for influenza, hepatitis B, pertussis, and shingles increased by small proportions, compared with the previous year, while pneumococcal disease coverage dropped slightly. Moreover, large racial disparities persisted for influenza immunization, with lower proportions of African Americans and Hispanics receiving the vaccine than whites.

"We have wonderful vaccination rates in young children ... but there are lower vaccination rates in adults, and they show us that maybe we’re starting to take vaccines and immunity for granted. This is one area where we cannot rest on our laurels. Our accomplishments will be undone if we don’t maintain our immunity as adults," Dr. Susan J. Rehm, medical director of the National Foundation for Infectious Diseases (NFID), said in a press briefing.

The NFID, which cosponsored the briefing with the CDC, also released the findings from its survey of 300 primary care physicians and 1,013 American consumers aged 18 years and older, which showed a distinct communication disconnect: Whereas 90% of the physicians said they discuss vaccines with their patients, 47% of the patients couldn’t recall ever discussing vaccines other than influenza with their doctors, and one-fifth couldn’t recall discussing any vaccines.

However, nearly 9 in 10 patients said that a strong recommendation from a physician would be a very likely motivator for them to get vaccinated. "Overall I think these findings are in a way encouraging. Although we have this disconnect, we have a solvable problem, and that is communication. Patients need to hear the recommendation from their provider, and it needs to be clear," said Dr. Rehm of the Cleveland Clinic.

She added that because adults typically visit the doctor for an acute problem and not for routine medical care, "every adult visit needs to be an immunization visit."

Dr. Melinda Wharton, deputy director of the CDC’s National Center for Immunization and Respiratory Diseases, reviewed the data from the 2009 NHIS. For influenza vaccine, there was an overall 2.3 percentage point increase among adults aged 19-49 years during the 2008-2009 season, compared with 2007-2008. While the increase was even greater for African Americans, 3.6 percentage points, their overall influenza immunization rate was just 16.5%, compared with 21.6% among whites. The percentage among Hispanics in that age group was 14.5%, up by just 1.5 percentage points.

For ever-receipt of pneumococcal vaccine among those for whom it is recommended, coverage among adults aged 19-64 years in 2009 was 17.5%, a drop of 7.4 percentage points since 2008. This is likely due in part to the recent addition of smokers and asthma patients to the high-risk list, Dr. Wharton said, noting that coverage among adults aged 65 years and older remained stable, at about 61%.

Immunization against hepatitis B among those at risk increased to the greatest degree among African Americans, rose by 13.6 percentage points to 43.6%, similar to the 43.2% among whites. Herpes zoster vaccine, on the other hand, increased by just 3.3 percentage points, from 6.7% of adults aged 60 years and older in 2008 to 10.0% in 2009. In 2009, the proportion of women aged 19-26 years who received human papillomavirus vaccination was just 17.1%, up by 6.6 percentage points from 10.5% in 2008.

Data for pertussis – which is receiving increased attention now because of the California outbreak – is reported via tetanus coverage. In 2005, the CDC recommended that the then-newly licensed adult/adolescent formula tetanus-diphtheria-pertussis vaccine (Tdap) replace a single dose of Td vaccine for individuals aged 10-64 years. Of adults aged 19-64 years who received a tetanus vaccine since 2005 and knew which kind of vaccine they had received, only 50.8% reported receiving Tdap.

The NHIS data also included health care provider immunization rates, which showed an overall 7.1 percentage point increase in influenza immunization from 2007 to 2008 to 52.9% in 2008-2009, a 1.6 percentage point increase in the proportion of tetanus vaccination during 2005-2009 given as Tdap, to 58.3% in 2009, and a slight 0.5 percentage point rise in ever-receipt of three doses of hepatitis B vaccine, reaching 64.7% in 2009.

Dr. Rehm noted that 57% of physicians reported in the NFID survey that they didn’t have adequate time to discuss vaccination during hurried office visits. But, she said, "The immunization discussion doesn’t need to be long. It needs to be concise and clear. When I talk with my patients, I don’t say ‘I think you should consider the vaccine,’ and so on. I simply say I recommend that you receive this vaccine.’ Data show that patients are quite receptive to that, and look to their providers for that recommendation."

The NFID has a new dedicated adult vaccination Web site for patients, www.adultvaccination.com.

Dr. Rehm has served as a speaker for Sanofi-Pasteur and Genentech, as a speaker and principal adviser for a research study for Cubist Pharmaceuticals Inc., and as an advisory committee member for Pfizer Inc. and Merck & Co. Inc. Dr. Wharton is an employee of CDC with no financial disclosures.

Adult immunization rates in the United States are improving but very slowly, according to new data from the Centers for Disease Control and Prevention released on Nov. 17.

Photo credit: U.S. Navy photo by Mass Communication Specialist 1st Class Todd Hack.

Overall, the 2009 National Health Interview Survey of 88,446 adults showed that adult immunization rates for influenza, hepatitis B, pertussis, and shingles increased by small proportions, compared with the previous year, while pneumococcal disease coverage dropped slightly. Moreover, large racial disparities persisted for influenza immunization, with lower proportions of African Americans and Hispanics receiving the vaccine than whites.

"We have wonderful vaccination rates in young children ... but there are lower vaccination rates in adults, and they show us that maybe we’re starting to take vaccines and immunity for granted. This is one area where we cannot rest on our laurels. Our accomplishments will be undone if we don’t maintain our immunity as adults," Dr. Susan J. Rehm, medical director of the National Foundation for Infectious Diseases (NFID), said in a press briefing.

The NFID, which cosponsored the briefing with the CDC, also released the findings from its survey of 300 primary care physicians and 1,013 American consumers aged 18 years and older, which showed a distinct communication disconnect: Whereas 90% of the physicians said they discuss vaccines with their patients, 47% of the patients couldn’t recall ever discussing vaccines other than influenza with their doctors, and one-fifth couldn’t recall discussing any vaccines.

However, nearly 9 in 10 patients said that a strong recommendation from a physician would be a very likely motivator for them to get vaccinated. "Overall I think these findings are in a way encouraging. Although we have this disconnect, we have a solvable problem, and that is communication. Patients need to hear the recommendation from their provider, and it needs to be clear," said Dr. Rehm of the Cleveland Clinic.

She added that because adults typically visit the doctor for an acute problem and not for routine medical care, "every adult visit needs to be an immunization visit."

Dr. Melinda Wharton, deputy director of the CDC’s National Center for Immunization and Respiratory Diseases, reviewed the data from the 2009 NHIS. For influenza vaccine, there was an overall 2.3 percentage point increase among adults aged 19-49 years during the 2008-2009 season, compared with 2007-2008. While the increase was even greater for African Americans, 3.6 percentage points, their overall influenza immunization rate was just 16.5%, compared with 21.6% among whites. The percentage among Hispanics in that age group was 14.5%, up by just 1.5 percentage points.

For ever-receipt of pneumococcal vaccine among those for whom it is recommended, coverage among adults aged 19-64 years in 2009 was 17.5%, a drop of 7.4 percentage points since 2008. This is likely due in part to the recent addition of smokers and asthma patients to the high-risk list, Dr. Wharton said, noting that coverage among adults aged 65 years and older remained stable, at about 61%.

Immunization against hepatitis B among those at risk increased to the greatest degree among African Americans, rose by 13.6 percentage points to 43.6%, similar to the 43.2% among whites. Herpes zoster vaccine, on the other hand, increased by just 3.3 percentage points, from 6.7% of adults aged 60 years and older in 2008 to 10.0% in 2009. In 2009, the proportion of women aged 19-26 years who received human papillomavirus vaccination was just 17.1%, up by 6.6 percentage points from 10.5% in 2008.

Data for pertussis – which is receiving increased attention now because of the California outbreak – is reported via tetanus coverage. In 2005, the CDC recommended that the then-newly licensed adult/adolescent formula tetanus-diphtheria-pertussis vaccine (Tdap) replace a single dose of Td vaccine for individuals aged 10-64 years. Of adults aged 19-64 years who received a tetanus vaccine since 2005 and knew which kind of vaccine they had received, only 50.8% reported receiving Tdap.

The NHIS data also included health care provider immunization rates, which showed an overall 7.1 percentage point increase in influenza immunization from 2007 to 2008 to 52.9% in 2008-2009, a 1.6 percentage point increase in the proportion of tetanus vaccination during 2005-2009 given as Tdap, to 58.3% in 2009, and a slight 0.5 percentage point rise in ever-receipt of three doses of hepatitis B vaccine, reaching 64.7% in 2009.

Dr. Rehm noted that 57% of physicians reported in the NFID survey that they didn’t have adequate time to discuss vaccination during hurried office visits. But, she said, "The immunization discussion doesn’t need to be long. It needs to be concise and clear. When I talk with my patients, I don’t say ‘I think you should consider the vaccine,’ and so on. I simply say I recommend that you receive this vaccine.’ Data show that patients are quite receptive to that, and look to their providers for that recommendation."

The NFID has a new dedicated adult vaccination Web site for patients, www.adultvaccination.com.

Dr. Rehm has served as a speaker for Sanofi-Pasteur and Genentech, as a speaker and principal adviser for a research study for Cubist Pharmaceuticals Inc., and as an advisory committee member for Pfizer Inc. and Merck & Co. Inc. Dr. Wharton is an employee of CDC with no financial disclosures.

Adult immunization rates in the United States are improving but very slowly, according to new data from the Centers for Disease Control and Prevention released on Nov. 17.

Photo credit: U.S. Navy photo by Mass Communication Specialist 1st Class Todd Hack.

Overall, the 2009 National Health Interview Survey of 88,446 adults showed that adult immunization rates for influenza, hepatitis B, pertussis, and shingles increased by small proportions, compared with the previous year, while pneumococcal disease coverage dropped slightly. Moreover, large racial disparities persisted for influenza immunization, with lower proportions of African Americans and Hispanics receiving the vaccine than whites.

"We have wonderful vaccination rates in young children ... but there are lower vaccination rates in adults, and they show us that maybe we’re starting to take vaccines and immunity for granted. This is one area where we cannot rest on our laurels. Our accomplishments will be undone if we don’t maintain our immunity as adults," Dr. Susan J. Rehm, medical director of the National Foundation for Infectious Diseases (NFID), said in a press briefing.

The NFID, which cosponsored the briefing with the CDC, also released the findings from its survey of 300 primary care physicians and 1,013 American consumers aged 18 years and older, which showed a distinct communication disconnect: Whereas 90% of the physicians said they discuss vaccines with their patients, 47% of the patients couldn’t recall ever discussing vaccines other than influenza with their doctors, and one-fifth couldn’t recall discussing any vaccines.

However, nearly 9 in 10 patients said that a strong recommendation from a physician would be a very likely motivator for them to get vaccinated. "Overall I think these findings are in a way encouraging. Although we have this disconnect, we have a solvable problem, and that is communication. Patients need to hear the recommendation from their provider, and it needs to be clear," said Dr. Rehm of the Cleveland Clinic.

She added that because adults typically visit the doctor for an acute problem and not for routine medical care, "every adult visit needs to be an immunization visit."

Dr. Melinda Wharton, deputy director of the CDC’s National Center for Immunization and Respiratory Diseases, reviewed the data from the 2009 NHIS. For influenza vaccine, there was an overall 2.3 percentage point increase among adults aged 19-49 years during the 2008-2009 season, compared with 2007-2008. While the increase was even greater for African Americans, 3.6 percentage points, their overall influenza immunization rate was just 16.5%, compared with 21.6% among whites. The percentage among Hispanics in that age group was 14.5%, up by just 1.5 percentage points.

For ever-receipt of pneumococcal vaccine among those for whom it is recommended, coverage among adults aged 19-64 years in 2009 was 17.5%, a drop of 7.4 percentage points since 2008. This is likely due in part to the recent addition of smokers and asthma patients to the high-risk list, Dr. Wharton said, noting that coverage among adults aged 65 years and older remained stable, at about 61%.

Immunization against hepatitis B among those at risk increased to the greatest degree among African Americans, rose by 13.6 percentage points to 43.6%, similar to the 43.2% among whites. Herpes zoster vaccine, on the other hand, increased by just 3.3 percentage points, from 6.7% of adults aged 60 years and older in 2008 to 10.0% in 2009. In 2009, the proportion of women aged 19-26 years who received human papillomavirus vaccination was just 17.1%, up by 6.6 percentage points from 10.5% in 2008.

Data for pertussis – which is receiving increased attention now because of the California outbreak – is reported via tetanus coverage. In 2005, the CDC recommended that the then-newly licensed adult/adolescent formula tetanus-diphtheria-pertussis vaccine (Tdap) replace a single dose of Td vaccine for individuals aged 10-64 years. Of adults aged 19-64 years who received a tetanus vaccine since 2005 and knew which kind of vaccine they had received, only 50.8% reported receiving Tdap.

The NHIS data also included health care provider immunization rates, which showed an overall 7.1 percentage point increase in influenza immunization from 2007 to 2008 to 52.9% in 2008-2009, a 1.6 percentage point increase in the proportion of tetanus vaccination during 2005-2009 given as Tdap, to 58.3% in 2009, and a slight 0.5 percentage point rise in ever-receipt of three doses of hepatitis B vaccine, reaching 64.7% in 2009.

Dr. Rehm noted that 57% of physicians reported in the NFID survey that they didn’t have adequate time to discuss vaccination during hurried office visits. But, she said, "The immunization discussion doesn’t need to be long. It needs to be concise and clear. When I talk with my patients, I don’t say ‘I think you should consider the vaccine,’ and so on. I simply say I recommend that you receive this vaccine.’ Data show that patients are quite receptive to that, and look to their providers for that recommendation."

The NFID has a new dedicated adult vaccination Web site for patients, www.adultvaccination.com.

Dr. Rehm has served as a speaker for Sanofi-Pasteur and Genentech, as a speaker and principal adviser for a research study for Cubist Pharmaceuticals Inc., and as an advisory committee member for Pfizer Inc. and Merck & Co. Inc. Dr. Wharton is an employee of CDC with no financial disclosures.

Adult immunization rates in the United States are improving but very slowly, according to new data from the Centers for Disease Control and Prevention released on Nov. 17.

Photo credit: U.S. Navy photo by Mass Communication Specialist 1st Class Todd Hack.

Overall, the 2009 National Health Interview Survey of 88,446 adults showed that adult immunization rates for influenza, hepatitis B, pertussis, and shingles increased by small proportions, compared with the previous year, while pneumococcal disease coverage dropped slightly. Moreover, large racial disparities persisted for influenza immunization, with lower proportions of African Americans and Hispanics receiving the vaccine than whites.

"We have wonderful vaccination rates in young children ... but there are lower vaccination rates in adults, and they show us that maybe we’re starting to take vaccines and immunity for granted. This is one area where we cannot rest on our laurels. Our accomplishments will be undone if we don’t maintain our immunity as adults," Dr. Susan J. Rehm, medical director of the National Foundation for Infectious Diseases (NFID), said in a press briefing.

The NFID, which cosponsored the briefing with the CDC, also released the findings from its survey of 300 primary care physicians and 1,013 American consumers aged 18 years and older, which showed a distinct communication disconnect: Whereas 90% of the physicians said they discuss vaccines with their patients, 47% of the patients couldn’t recall ever discussing vaccines other than influenza with their doctors, and one-fifth couldn’t recall discussing any vaccines.

However, nearly 9 in 10 patients said that a strong recommendation from a physician would be a very likely motivator for them to get vaccinated. "Overall I think these findings are in a way encouraging. Although we have this disconnect, we have a solvable problem, and that is communication. Patients need to hear the recommendation from their provider, and it needs to be clear," said Dr. Rehm of the Cleveland Clinic.

She added that because adults typically visit the doctor for an acute problem and not for routine medical care, "every adult visit needs to be an immunization visit."

Dr. Melinda Wharton, deputy director of the CDC’s National Center for Immunization and Respiratory Diseases, reviewed the data from the 2009 NHIS. For influenza vaccine, there was an overall 2.3 percentage point increase among adults aged 19-49 years during the 2008-2009 season, compared with 2007-2008. While the increase was even greater for African Americans, 3.6 percentage points, their overall influenza immunization rate was just 16.5%, compared with 21.6% among whites. The percentage among Hispanics in that age group was 14.5%, up by just 1.5 percentage points.

For ever-receipt of pneumococcal vaccine among those for whom it is recommended, coverage among adults aged 19-64 years in 2009 was 17.5%, a drop of 7.4 percentage points since 2008. This is likely due in part to the recent addition of smokers and asthma patients to the high-risk list, Dr. Wharton said, noting that coverage among adults aged 65 years and older remained stable, at about 61%.

Immunization against hepatitis B among those at risk increased to the greatest degree among African Americans, rose by 13.6 percentage points to 43.6%, similar to the 43.2% among whites. Herpes zoster vaccine, on the other hand, increased by just 3.3 percentage points, from 6.7% of adults aged 60 years and older in 2008 to 10.0% in 2009. In 2009, the proportion of women aged 19-26 years who received human papillomavirus vaccination was just 17.1%, up by 6.6 percentage points from 10.5% in 2008.

Data for pertussis – which is receiving increased attention now because of the California outbreak – is reported via tetanus coverage. In 2005, the CDC recommended that the then-newly licensed adult/adolescent formula tetanus-diphtheria-pertussis vaccine (Tdap) replace a single dose of Td vaccine for individuals aged 10-64 years. Of adults aged 19-64 years who received a tetanus vaccine since 2005 and knew which kind of vaccine they had received, only 50.8% reported receiving Tdap.

The NHIS data also included health care provider immunization rates, which showed an overall 7.1 percentage point increase in influenza immunization from 2007 to 2008 to 52.9% in 2008-2009, a 1.6 percentage point increase in the proportion of tetanus vaccination during 2005-2009 given as Tdap, to 58.3% in 2009, and a slight 0.5 percentage point rise in ever-receipt of three doses of hepatitis B vaccine, reaching 64.7% in 2009.

Dr. Rehm noted that 57% of physicians reported in the NFID survey that they didn’t have adequate time to discuss vaccination during hurried office visits. But, she said, "The immunization discussion doesn’t need to be long. It needs to be concise and clear. When I talk with my patients, I don’t say ‘I think you should consider the vaccine,’ and so on. I simply say I recommend that you receive this vaccine.’ Data show that patients are quite receptive to that, and look to their providers for that recommendation."

The NFID has a new dedicated adult vaccination Web site for patients, www.adultvaccination.com.

Dr. Rehm has served as a speaker for Sanofi-Pasteur and Genentech, as a speaker and principal adviser for a research study for Cubist Pharmaceuticals Inc., and as an advisory committee member for Pfizer Inc. and Merck & Co. Inc. Dr. Wharton is an employee of CDC with no financial disclosures.

Adult immunization rates in the United States are improving but very slowly, according to new data from the Centers for Disease Control and Prevention released on Nov. 17.

Photo credit: U.S. Navy photo by Mass Communication Specialist 1st Class Todd Hack.

Overall, the 2009 National Health Interview Survey of 88,446 adults showed that adult immunization rates for influenza, hepatitis B, pertussis, and shingles increased by small proportions, compared with the previous year, while pneumococcal disease coverage dropped slightly. Moreover, large racial disparities persisted for influenza immunization, with lower proportions of African Americans and Hispanics receiving the vaccine than whites.

"We have wonderful vaccination rates in young children ... but there are lower vaccination rates in adults, and they show us that maybe we’re starting to take vaccines and immunity for granted. This is one area where we cannot rest on our laurels. Our accomplishments will be undone if we don’t maintain our immunity as adults," Dr. Susan J. Rehm, medical director of the National Foundation for Infectious Diseases (NFID), said in a press briefing.

The NFID, which cosponsored the briefing with the CDC, also released the findings from its survey of 300 primary care physicians and 1,013 American consumers aged 18 years and older, which showed a distinct communication disconnect: Whereas 90% of the physicians said they discuss vaccines with their patients, 47% of the patients couldn’t recall ever discussing vaccines other than influenza with their doctors, and one-fifth couldn’t recall discussing any vaccines.

However, nearly 9 in 10 patients said that a strong recommendation from a physician would be a very likely motivator for them to get vaccinated. "Overall I think these findings are in a way encouraging. Although we have this disconnect, we have a solvable problem, and that is communication. Patients need to hear the recommendation from their provider, and it needs to be clear," said Dr. Rehm of the Cleveland Clinic.

She added that because adults typically visit the doctor for an acute problem and not for routine medical care, "every adult visit needs to be an immunization visit."

Dr. Melinda Wharton, deputy director of the CDC’s National Center for Immunization and Respiratory Diseases, reviewed the data from the 2009 NHIS. For influenza vaccine, there was an overall 2.3 percentage point increase among adults aged 19-49 years during the 2008-2009 season, compared with 2007-2008. While the increase was even greater for African Americans, 3.6 percentage points, their overall influenza immunization rate was just 16.5%, compared with 21.6% among whites. The percentage among Hispanics in that age group was 14.5%, up by just 1.5 percentage points.

For ever-receipt of pneumococcal vaccine among those for whom it is recommended, coverage among adults aged 19-64 years in 2009 was 17.5%, a drop of 7.4 percentage points since 2008. This is likely due in part to the recent addition of smokers and asthma patients to the high-risk list, Dr. Wharton said, noting that coverage among adults aged 65 years and older remained stable, at about 61%.

Immunization against hepatitis B among those at risk increased to the greatest degree among African Americans, rose by 13.6 percentage points to 43.6%, similar to the 43.2% among whites. Herpes zoster vaccine, on the other hand, increased by just 3.3 percentage points, from 6.7% of adults aged 60 years and older in 2008 to 10.0% in 2009. In 2009, the proportion of women aged 19-26 years who received human papillomavirus vaccination was just 17.1%, up by 6.6 percentage points from 10.5% in 2008.

Data for pertussis – which is receiving increased attention now because of the California outbreak – is reported via tetanus coverage. In 2005, the CDC recommended that the then-newly licensed adult/adolescent formula tetanus-diphtheria-pertussis vaccine (Tdap) replace a single dose of Td vaccine for individuals aged 10-64 years. Of adults aged 19-64 years who received a tetanus vaccine since 2005 and knew which kind of vaccine they had received, only 50.8% reported receiving Tdap.

The NHIS data also included health care provider immunization rates, which showed an overall 7.1 percentage point increase in influenza immunization from 2007 to 2008 to 52.9% in 2008-2009, a 1.6 percentage point increase in the proportion of tetanus vaccination during 2005-2009 given as Tdap, to 58.3% in 2009, and a slight 0.5 percentage point rise in ever-receipt of three doses of hepatitis B vaccine, reaching 64.7% in 2009.

Dr. Rehm noted that 57% of physicians reported in the NFID survey that they didn’t have adequate time to discuss vaccination during hurried office visits. But, she said, "The immunization discussion doesn’t need to be long. It needs to be concise and clear. When I talk with my patients, I don’t say ‘I think you should consider the vaccine,’ and so on. I simply say I recommend that you receive this vaccine.’ Data show that patients are quite receptive to that, and look to their providers for that recommendation."

The NFID has a new dedicated adult vaccination Web site for patients, www.adultvaccination.com.

Dr. Rehm has served as a speaker for Sanofi-Pasteur and Genentech, as a speaker and principal adviser for a research study for Cubist Pharmaceuticals Inc., and as an advisory committee member for Pfizer Inc. and Merck & Co. Inc. Dr. Wharton is an employee of CDC with no financial disclosures.

Adult immunization rates in the United States are improving but very slowly, according to new data from the Centers for Disease Control and Prevention released on Nov. 17.

Photo credit: U.S. Navy photo by Mass Communication Specialist 1st Class Todd Hack.

Overall, the 2009 National Health Interview Survey of 88,446 adults showed that adult immunization rates for influenza, hepatitis B, pertussis, and shingles increased by small proportions, compared with the previous year, while pneumococcal disease coverage dropped slightly. Moreover, large racial disparities persisted for influenza immunization, with lower proportions of African Americans and Hispanics receiving the vaccine than whites.

"We have wonderful vaccination rates in young children ... but there are lower vaccination rates in adults, and they show us that maybe we’re starting to take vaccines and immunity for granted. This is one area where we cannot rest on our laurels. Our accomplishments will be undone if we don’t maintain our immunity as adults," Dr. Susan J. Rehm, medical director of the National Foundation for Infectious Diseases (NFID), said in a press briefing.

The NFID, which cosponsored the briefing with the CDC, also released the findings from its survey of 300 primary care physicians and 1,013 American consumers aged 18 years and older, which showed a distinct communication disconnect: Whereas 90% of the physicians said they discuss vaccines with their patients, 47% of the patients couldn’t recall ever discussing vaccines other than influenza with their doctors, and one-fifth couldn’t recall discussing any vaccines.

However, nearly 9 in 10 patients said that a strong recommendation from a physician would be a very likely motivator for them to get vaccinated. "Overall I think these findings are in a way encouraging. Although we have this disconnect, we have a solvable problem, and that is communication. Patients need to hear the recommendation from their provider, and it needs to be clear," said Dr. Rehm of the Cleveland Clinic.

She added that because adults typically visit the doctor for an acute problem and not for routine medical care, "every adult visit needs to be an immunization visit."

Dr. Melinda Wharton, deputy director of the CDC’s National Center for Immunization and Respiratory Diseases, reviewed the data from the 2009 NHIS. For influenza vaccine, there was an overall 2.3 percentage point increase among adults aged 19-49 years during the 2008-2009 season, compared with 2007-2008. While the increase was even greater for African Americans, 3.6 percentage points, their overall influenza immunization rate was just 16.5%, compared with 21.6% among whites. The percentage among Hispanics in that age group was 14.5%, up by just 1.5 percentage points.

For ever-receipt of pneumococcal vaccine among those for whom it is recommended, coverage among adults aged 19-64 years in 2009 was 17.5%, a drop of 7.4 percentage points since 2008. This is likely due in part to the recent addition of smokers and asthma patients to the high-risk list, Dr. Wharton said, noting that coverage among adults aged 65 years and older remained stable, at about 61%.

Immunization against hepatitis B among those at risk increased to the greatest degree among African Americans, rose by 13.6 percentage points to 43.6%, similar to the 43.2% among whites. Herpes zoster vaccine, on the other hand, increased by just 3.3 percentage points, from 6.7% of adults aged 60 years and older in 2008 to 10.0% in 2009. In 2009, the proportion of women aged 19-26 years who received human papillomavirus vaccination was just 17.1%, up by 6.6 percentage points from 10.5% in 2008.

Data for pertussis – which is receiving increased attention now because of the California outbreak – is reported via tetanus coverage. In 2005, the CDC recommended that the then-newly licensed adult/adolescent formula tetanus-diphtheria-pertussis vaccine (Tdap) replace a single dose of Td vaccine for individuals aged 10-64 years. Of adults aged 19-64 years who received a tetanus vaccine since 2005 and knew which kind of vaccine they had received, only 50.8% reported receiving Tdap.

The NHIS data also included health care provider immunization rates, which showed an overall 7.1 percentage point increase in influenza immunization from 2007 to 2008 to 52.9% in 2008-2009, a 1.6 percentage point increase in the proportion of tetanus vaccination during 2005-2009 given as Tdap, to 58.3% in 2009, and a slight 0.5 percentage point rise in ever-receipt of three doses of hepatitis B vaccine, reaching 64.7% in 2009.

Dr. Rehm noted that 57% of physicians reported in the NFID survey that they didn’t have adequate time to discuss vaccination during hurried office visits. But, she said, "The immunization discussion doesn’t need to be long. It needs to be concise and clear. When I talk with my patients, I don’t say ‘I think you should consider the vaccine,’ and so on. I simply say I recommend that you receive this vaccine.’ Data show that patients are quite receptive to that, and look to their providers for that recommendation."

The NFID has a new dedicated adult vaccination Web site for patients, www.adultvaccination.com.

Dr. Rehm has served as a speaker for Sanofi-Pasteur and Genentech, as a speaker and principal adviser for a research study for Cubist Pharmaceuticals Inc., and as an advisory committee member for Pfizer Inc. and Merck & Co. Inc. Dr. Wharton is an employee of CDC with no financial disclosures.

Should you use computed tomography or magnetic resonance imaging in the acute stroke setting? There are no easy answers to this question, according to Dr. Todd S. Miller.

Although CT has been the mainstay of acute stroke diagnosis for more than 2 decades, new practice guidelines state that diffusion weighted imaging (DWI) "should be considered more useful than noncontrast CT for the diagnosis of acute ischemic stroke within 12 hours of symptom onset" (Neurology 2010;75:177-85).

Historically, cost, time, and availability have favored CT in the acute stroke setting. MRI offers superior infarct visualization, but it is slower. In the emergency setting, there is pressure to quickly treat patients with cerebral ischemia, while triaging those whose symptoms are explained by alternative diagnoses.

The controversy overlies a background in which only a minority of stroke patients receive any intervention, said Dr. Miller, assistant professor of neuroradiology at Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, N.Y.

"In the acute stroke setting, there’s a significant opportunity to improve outcomes. But as reported as recently as 2009, only 1% of patients (Emerg. Med. Clin. North Am. 2009;27:115-9) who are having a stroke receive thrombolytic therapy," he said in an interview.

"In the United States, stroke is still a major cause of long-term disability, with huge economic and social costs. We want to identify individuals who are having an infarct and try to determine who we can help to improve functional outcomes," he added at the Veith symposium on vascular medicine sponsored by the Cleveland Clinic.

For patients who reach the hospital within 3 hours and for whom hemorrhage and stroke mimics are ruled out via noncontrast CT, the choice of imaging to assess the infarct core to guide treatment usually is based on experience and availability. "Although MRI is clearly more sensitive and specific, quite a few studies have suggested that both CT angiography [CTA] and CT perfusion are adequate. Use whatever is available," he said.

In a comparison of CT perfusion imaging (CTP) and MR DWI in 23 consecutive patients presenting within 12 hours of stroke onset, DWI was more sensitive than was CTP for parenchymal stroke detection, but both modalities were highly accurate predictors of final infarct volume. While DWI tended to underestimate final infarct size, CTP more closely approximated final infarct size (Stroke 2001;32:317).

Other data also suggest that the presence of hyperattenuation on CTP may predict hemorrhage (AJNR Am. J. Neuroradiol. 2007;28:1292-8). Identification of those at risk for hemorrhage allows clinicians to avoid doing harm and causing a worsening of symptoms.

Some clinicians are reluctant to use iodinated contrast for CTA/CTP because of concerns about contrast nephropathy. But in a retrospective study of 224 patients who had received CTA of the brain or neck to evaluate acute stroke syndrome, just 7 (3%) met the criteria for radiocontrast nephropathy, including 2 of 93 (2%) who had emergent CTA without knowledge of their creatinine value. None needed dialysis (Stroke 2007;38:2364-6).

Taken together, the data support CT for evaluating the core infarct and penumbra in stroke patients, as well as for predicting outcome from antithrombotic therapy. MRI allows far better visualization, but it’s hard to get patients into the magnet, it can’t be used in certain patients with metal in their bodies, and it isn’t available in many institutions.

Dr. Miller acknowledged his pro-CT bias, but he said a recent article has caused him to think twice. The study, involving 174 patients with presumed stroke, showed that without significantly increasing door-to-needle time, MRI was feasible in 88% of 161 who required acute imaging and that it supported treat/not treat decisions (Acta. Neurol. Scand. 2009;120:143-9).

"It has not been my experience that MRI and CT take an equal amount of time for the evaluation of acute cerebral ischemia, but if that is the case for you in your center, the evidence clearly favors MRI. Otherwise, CT is king," he said.

Should you use computed tomography or magnetic resonance imaging in the acute stroke setting? There are no easy answers to this question, according to Dr. Todd S. Miller.

Although CT has been the mainstay of acute stroke diagnosis for more than 2 decades, new practice guidelines state that diffusion weighted imaging (DWI) "should be considered more useful than noncontrast CT for the diagnosis of acute ischemic stroke within 12 hours of symptom onset" (Neurology 2010;75:177-85).

Historically, cost, time, and availability have favored CT in the acute stroke setting. MRI offers superior infarct visualization, but it is slower. In the emergency setting, there is pressure to quickly treat patients with cerebral ischemia, while triaging those whose symptoms are explained by alternative diagnoses.

The controversy overlies a background in which only a minority of stroke patients receive any intervention, said Dr. Miller, assistant professor of neuroradiology at Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, N.Y.

"In the acute stroke setting, there’s a significant opportunity to improve outcomes. But as reported as recently as 2009, only 1% of patients (Emerg. Med. Clin. North Am. 2009;27:115-9) who are having a stroke receive thrombolytic therapy," he said in an interview.

"In the United States, stroke is still a major cause of long-term disability, with huge economic and social costs. We want to identify individuals who are having an infarct and try to determine who we can help to improve functional outcomes," he added at the Veith symposium on vascular medicine sponsored by the Cleveland Clinic.

For patients who reach the hospital within 3 hours and for whom hemorrhage and stroke mimics are ruled out via noncontrast CT, the choice of imaging to assess the infarct core to guide treatment usually is based on experience and availability. "Although MRI is clearly more sensitive and specific, quite a few studies have suggested that both CT angiography [CTA] and CT perfusion are adequate. Use whatever is available," he said.

In a comparison of CT perfusion imaging (CTP) and MR DWI in 23 consecutive patients presenting within 12 hours of stroke onset, DWI was more sensitive than was CTP for parenchymal stroke detection, but both modalities were highly accurate predictors of final infarct volume. While DWI tended to underestimate final infarct size, CTP more closely approximated final infarct size (Stroke 2001;32:317).

Other data also suggest that the presence of hyperattenuation on CTP may predict hemorrhage (AJNR Am. J. Neuroradiol. 2007;28:1292-8). Identification of those at risk for hemorrhage allows clinicians to avoid doing harm and causing a worsening of symptoms.

Some clinicians are reluctant to use iodinated contrast for CTA/CTP because of concerns about contrast nephropathy. But in a retrospective study of 224 patients who had received CTA of the brain or neck to evaluate acute stroke syndrome, just 7 (3%) met the criteria for radiocontrast nephropathy, including 2 of 93 (2%) who had emergent CTA without knowledge of their creatinine value. None needed dialysis (Stroke 2007;38:2364-6).

Taken together, the data support CT for evaluating the core infarct and penumbra in stroke patients, as well as for predicting outcome from antithrombotic therapy. MRI allows far better visualization, but it’s hard to get patients into the magnet, it can’t be used in certain patients with metal in their bodies, and it isn’t available in many institutions.

Dr. Miller acknowledged his pro-CT bias, but he said a recent article has caused him to think twice. The study, involving 174 patients with presumed stroke, showed that without significantly increasing door-to-needle time, MRI was feasible in 88% of 161 who required acute imaging and that it supported treat/not treat decisions (Acta. Neurol. Scand. 2009;120:143-9).

"It has not been my experience that MRI and CT take an equal amount of time for the evaluation of acute cerebral ischemia, but if that is the case for you in your center, the evidence clearly favors MRI. Otherwise, CT is king," he said.

Should you use computed tomography or magnetic resonance imaging in the acute stroke setting? There are no easy answers to this question, according to Dr. Todd S. Miller.

Although CT has been the mainstay of acute stroke diagnosis for more than 2 decades, new practice guidelines state that diffusion weighted imaging (DWI) "should be considered more useful than noncontrast CT for the diagnosis of acute ischemic stroke within 12 hours of symptom onset" (Neurology 2010;75:177-85).

Historically, cost, time, and availability have favored CT in the acute stroke setting. MRI offers superior infarct visualization, but it is slower. In the emergency setting, there is pressure to quickly treat patients with cerebral ischemia, while triaging those whose symptoms are explained by alternative diagnoses.

The controversy overlies a background in which only a minority of stroke patients receive any intervention, said Dr. Miller, assistant professor of neuroradiology at Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, N.Y.

"In the acute stroke setting, there’s a significant opportunity to improve outcomes. But as reported as recently as 2009, only 1% of patients (Emerg. Med. Clin. North Am. 2009;27:115-9) who are having a stroke receive thrombolytic therapy," he said in an interview.

"In the United States, stroke is still a major cause of long-term disability, with huge economic and social costs. We want to identify individuals who are having an infarct and try to determine who we can help to improve functional outcomes," he added at the Veith symposium on vascular medicine sponsored by the Cleveland Clinic.

For patients who reach the hospital within 3 hours and for whom hemorrhage and stroke mimics are ruled out via noncontrast CT, the choice of imaging to assess the infarct core to guide treatment usually is based on experience and availability. "Although MRI is clearly more sensitive and specific, quite a few studies have suggested that both CT angiography [CTA] and CT perfusion are adequate. Use whatever is available," he said.

In a comparison of CT perfusion imaging (CTP) and MR DWI in 23 consecutive patients presenting within 12 hours of stroke onset, DWI was more sensitive than was CTP for parenchymal stroke detection, but both modalities were highly accurate predictors of final infarct volume. While DWI tended to underestimate final infarct size, CTP more closely approximated final infarct size (Stroke 2001;32:317).

Other data also suggest that the presence of hyperattenuation on CTP may predict hemorrhage (AJNR Am. J. Neuroradiol. 2007;28:1292-8). Identification of those at risk for hemorrhage allows clinicians to avoid doing harm and causing a worsening of symptoms.

Some clinicians are reluctant to use iodinated contrast for CTA/CTP because of concerns about contrast nephropathy. But in a retrospective study of 224 patients who had received CTA of the brain or neck to evaluate acute stroke syndrome, just 7 (3%) met the criteria for radiocontrast nephropathy, including 2 of 93 (2%) who had emergent CTA without knowledge of their creatinine value. None needed dialysis (Stroke 2007;38:2364-6).

Taken together, the data support CT for evaluating the core infarct and penumbra in stroke patients, as well as for predicting outcome from antithrombotic therapy. MRI allows far better visualization, but it’s hard to get patients into the magnet, it can’t be used in certain patients with metal in their bodies, and it isn’t available in many institutions.

Dr. Miller acknowledged his pro-CT bias, but he said a recent article has caused him to think twice. The study, involving 174 patients with presumed stroke, showed that without significantly increasing door-to-needle time, MRI was feasible in 88% of 161 who required acute imaging and that it supported treat/not treat decisions (Acta. Neurol. Scand. 2009;120:143-9).

"It has not been my experience that MRI and CT take an equal amount of time for the evaluation of acute cerebral ischemia, but if that is the case for you in your center, the evidence clearly favors MRI. Otherwise, CT is king," he said.

ATLANTA – A booster dose of meningococcal conjugate vaccine should be given to adolescents at 16 years of age if they received a first dose at age 11-12 years, and a booster should be given 5 years after the first dose – up to age 21 years – to those who first received the vaccine at age 13-15 years.

That was the vote of the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention on Oct. 27th, but it was not unanimous. The panel was split 6 to 5, with 3 abstentions. Following that vote, ACIP also voted to include the booster dose under the federal Vaccines for Children program. The CDC usually adopts the ACIP's recommendations but is not obligated to do so.

In 2007, ACIP recommended that the quadrivalent meningococcal conjugate vaccine (MCV4), sold under the brand names Menactra and Menveo, be given to 11- to 12-year-olds at the established preteen visit, and to 13- to 18-year-olds who had not been previously vaccinated.

At that time, it was assumed that this would protect teenagers through the peak age in disease seen in 16- to 21-year-olds, said Dr. Amanda Cohn of the CDC's National Center for Immunization and Respiratory Diseases (NCIRD).

However, recent data have suggested that immunity from the vaccine wanes within 5 years after vaccination, thereby possibly failing to protect those at highest risk, particularly college students living in dorms. “We're missing protecting the group that the recommendation was intended to protect,” Dr. Cohn commented.

A cost-effectiveness analysis presented at the ACIP meeting by Dr. Ismael Ortega-Sanchez, also with the NCIRD, showed that giving just one dose of MCV4 to all 11-year-olds was the least cost-effective of several options the ACIP considered, at $281,000 per quality adjusted life year (QALY).

Giving one dose just to 15-year-olds would cost $121,000/QALY, while giving doses to all 11-year-olds and 16-year-olds – the option chosen – comes to $157,000/QALY.

For comparison, vaccinating all healthy 12- to 17-year-olds against influenza – already recommended by CDC – costs $128,000/QALY, Dr. Ortega-Sanchez said.

Despite the emerging evidence that the current practice of giving MCV4 vaccine to 11- to 12-year-olds is not the ideal option, many panel members and audience members expressed concern about removing the recommendation to give the vaccine at that age since it is part of the now-established preadolescent vaccination visit “platform” that also includes human papillomavirus and diphtheria-tetanus-pertussis vaccinations. Moreover, it does protect those aged 11- to 13-years-old against meningococcal disease.

While the evidence is now clear that the level of protective antibody against Neisseria meningitidis drops to suboptimal levels 5 years after receipt of MCV4, the level of disease does not appear to have been affected yet.

Indeed, “We are currently at historic low rates of meningococcal disease,” Dr. Cohn said, adding that the ACIP working group's aim was to make a change in order to prevent those rates from rising again.

However, the sizable minority of the panel who opposed the addition of the booster dose for 16-year-olds cited cost and lack of cost-effectiveness. Among them was ACIP member Dr. Lance Chilton. “I'm worried that we don't have data that would support cost-effectiveness of a 2-dose regimen. It's certainly better than the current 11- to 12-year only vaccination, but to me the cost-effectiveness data don't justify [the vote],” he said in an interview.

Dr. Chilton of the University of New Mexico, Albuquerque, said he would have preferred simply giving MCV4 at mid-adolescence. “I'm in favor of the preadolescent platform, but I don't think that changing the MCV4 to age 15-16 [years] would appreciably diminish that platform. Adding another platform is probably a good idea.”

As CDC employees, Dr. Cohn and Dr. Ortega-Sanchez have no financial conflicts. Dr. Chilton stated at the beginning of the meeting that he also had no conflicts of interest.

ATLANTA – A booster dose of meningococcal conjugate vaccine should be given to adolescents at 16 years of age if they received a first dose at age 11-12 years, and a booster should be given 5 years after the first dose – up to age 21 years – to those who first received the vaccine at age 13-15 years.

That was the vote of the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention on Oct. 27th, but it was not unanimous. The panel was split 6 to 5, with 3 abstentions. Following that vote, ACIP also voted to include the booster dose under the federal Vaccines for Children program. The CDC usually adopts the ACIP's recommendations but is not obligated to do so.

In 2007, ACIP recommended that the quadrivalent meningococcal conjugate vaccine (MCV4), sold under the brand names Menactra and Menveo, be given to 11- to 12-year-olds at the established preteen visit, and to 13- to 18-year-olds who had not been previously vaccinated.

At that time, it was assumed that this would protect teenagers through the peak age in disease seen in 16- to 21-year-olds, said Dr. Amanda Cohn of the CDC's National Center for Immunization and Respiratory Diseases (NCIRD).

However, recent data have suggested that immunity from the vaccine wanes within 5 years after vaccination, thereby possibly failing to protect those at highest risk, particularly college students living in dorms. “We're missing protecting the group that the recommendation was intended to protect,” Dr. Cohn commented.

A cost-effectiveness analysis presented at the ACIP meeting by Dr. Ismael Ortega-Sanchez, also with the NCIRD, showed that giving just one dose of MCV4 to all 11-year-olds was the least cost-effective of several options the ACIP considered, at $281,000 per quality adjusted life year (QALY).

Giving one dose just to 15-year-olds would cost $121,000/QALY, while giving doses to all 11-year-olds and 16-year-olds – the option chosen – comes to $157,000/QALY.

For comparison, vaccinating all healthy 12- to 17-year-olds against influenza – already recommended by CDC – costs $128,000/QALY, Dr. Ortega-Sanchez said.

Despite the emerging evidence that the current practice of giving MCV4 vaccine to 11- to 12-year-olds is not the ideal option, many panel members and audience members expressed concern about removing the recommendation to give the vaccine at that age since it is part of the now-established preadolescent vaccination visit “platform” that also includes human papillomavirus and diphtheria-tetanus-pertussis vaccinations. Moreover, it does protect those aged 11- to 13-years-old against meningococcal disease.

While the evidence is now clear that the level of protective antibody against Neisseria meningitidis drops to suboptimal levels 5 years after receipt of MCV4, the level of disease does not appear to have been affected yet.

Indeed, “We are currently at historic low rates of meningococcal disease,” Dr. Cohn said, adding that the ACIP working group's aim was to make a change in order to prevent those rates from rising again.

However, the sizable minority of the panel who opposed the addition of the booster dose for 16-year-olds cited cost and lack of cost-effectiveness. Among them was ACIP member Dr. Lance Chilton. “I'm worried that we don't have data that would support cost-effectiveness of a 2-dose regimen. It's certainly better than the current 11- to 12-year only vaccination, but to me the cost-effectiveness data don't justify [the vote],” he said in an interview.

Dr. Chilton of the University of New Mexico, Albuquerque, said he would have preferred simply giving MCV4 at mid-adolescence. “I'm in favor of the preadolescent platform, but I don't think that changing the MCV4 to age 15-16 [years] would appreciably diminish that platform. Adding another platform is probably a good idea.”

As CDC employees, Dr. Cohn and Dr. Ortega-Sanchez have no financial conflicts. Dr. Chilton stated at the beginning of the meeting that he also had no conflicts of interest.

ATLANTA – A booster dose of meningococcal conjugate vaccine should be given to adolescents at 16 years of age if they received a first dose at age 11-12 years, and a booster should be given 5 years after the first dose – up to age 21 years – to those who first received the vaccine at age 13-15 years.

That was the vote of the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention on Oct. 27th, but it was not unanimous. The panel was split 6 to 5, with 3 abstentions. Following that vote, ACIP also voted to include the booster dose under the federal Vaccines for Children program. The CDC usually adopts the ACIP's recommendations but is not obligated to do so.

In 2007, ACIP recommended that the quadrivalent meningococcal conjugate vaccine (MCV4), sold under the brand names Menactra and Menveo, be given to 11- to 12-year-olds at the established preteen visit, and to 13- to 18-year-olds who had not been previously vaccinated.

At that time, it was assumed that this would protect teenagers through the peak age in disease seen in 16- to 21-year-olds, said Dr. Amanda Cohn of the CDC's National Center for Immunization and Respiratory Diseases (NCIRD).

However, recent data have suggested that immunity from the vaccine wanes within 5 years after vaccination, thereby possibly failing to protect those at highest risk, particularly college students living in dorms. “We're missing protecting the group that the recommendation was intended to protect,” Dr. Cohn commented.

A cost-effectiveness analysis presented at the ACIP meeting by Dr. Ismael Ortega-Sanchez, also with the NCIRD, showed that giving just one dose of MCV4 to all 11-year-olds was the least cost-effective of several options the ACIP considered, at $281,000 per quality adjusted life year (QALY).

Giving one dose just to 15-year-olds would cost $121,000/QALY, while giving doses to all 11-year-olds and 16-year-olds – the option chosen – comes to $157,000/QALY.

For comparison, vaccinating all healthy 12- to 17-year-olds against influenza – already recommended by CDC – costs $128,000/QALY, Dr. Ortega-Sanchez said.

Despite the emerging evidence that the current practice of giving MCV4 vaccine to 11- to 12-year-olds is not the ideal option, many panel members and audience members expressed concern about removing the recommendation to give the vaccine at that age since it is part of the now-established preadolescent vaccination visit “platform” that also includes human papillomavirus and diphtheria-tetanus-pertussis vaccinations. Moreover, it does protect those aged 11- to 13-years-old against meningococcal disease.

While the evidence is now clear that the level of protective antibody against Neisseria meningitidis drops to suboptimal levels 5 years after receipt of MCV4, the level of disease does not appear to have been affected yet.

Indeed, “We are currently at historic low rates of meningococcal disease,” Dr. Cohn said, adding that the ACIP working group's aim was to make a change in order to prevent those rates from rising again.

However, the sizable minority of the panel who opposed the addition of the booster dose for 16-year-olds cited cost and lack of cost-effectiveness. Among them was ACIP member Dr. Lance Chilton. “I'm worried that we don't have data that would support cost-effectiveness of a 2-dose regimen. It's certainly better than the current 11- to 12-year only vaccination, but to me the cost-effectiveness data don't justify [the vote],” he said in an interview.

Dr. Chilton of the University of New Mexico, Albuquerque, said he would have preferred simply giving MCV4 at mid-adolescence. “I'm in favor of the preadolescent platform, but I don't think that changing the MCV4 to age 15-16 [years] would appreciably diminish that platform. Adding another platform is probably a good idea.”

As CDC employees, Dr. Cohn and Dr. Ortega-Sanchez have no financial conflicts. Dr. Chilton stated at the beginning of the meeting that he also had no conflicts of interest.

STOCKHOLM – Use of a “rule-in” hemoglobin A_1c cut point of 6.8% and a “rule-out” value of 5.8%, with glucose testing for individuals who fall in the middle of the diagnostic cutoff, was more accurate in diagnosing type 2 diabetes than was a single cutoff value of 6.5%.

The finding from a multiethnic cohort study of 8,696 previously undiagnosed primary care patients addresses some of the concerns about false-positive and false-negative diagnoses associated with using a single measure of hemoglobin A_1c. Multiple studies have shown that the 6.5% cutoff may be discordant with the results of an oral glucose tolerance test (OGTT), which is considered to be the standard diagnostic test for type 2 diabetes, said Dr. Samiul A. Mostafa, a clinical research fellow in the diabetes research unit of the University of Leicester (England).

In July 2009, an international expert committee recommended the use of hemoglobin A_1c for diagnosing diabetes, with a diagnostic cutoff of 6.5% or above following a repeat confirmatory A_1c test (Diabetes Care 2009;32:1327-34). In January 2010, the American Diabetes Association endorsed that recommendation (Diabetes Care 2010;33[suppl. 1]:S62-9). The European Association for the Study of Diabetes and the World Health Organization are expected to issue similar statements soon.

The study participants were identified from two systematic screening programs during 2002-2008. Three-quarters (75%) were white Europeans and 23% were South Asians from Pakistan, Bangladesh, and India. The mean HbA_1c for the entire cohort was 5.7%. All underwent an OGTT and also had their HbA_1c levels measured. Using the WHO criteria (a 2-hour plasma glucose level of 200 mg/dL or above, following a 75-g glucose load), the OGTT detected 291 individuals (3.3% of 8,696 study participants) with type 2 diabetes.

Among the white Europeans, use of the 6.5% A_1c cutoff had a sensitivity of 62% and a positive predictive value of 45%. Based on an Australian study published earlier this year, the investigators chose to compare those values with a rule-out A_1c cutoff of 5.5% and a rule-in cutoff of 7.0%, with a confirmatory OGTT used for those falling in between (Diabetes Care 2010;33:817-9).

That method gave an improved sensitivity of 98% and positive predictive value of 76% in the white European group. With either method, specificity and negative predictive values were close to 100%. For the South Asians, the 6.5% cutoff gave a sensitivity of 79% and positive predictive value of 36%, both of which improved to 99% and 68%, respectively, with the two–cut-point criteria. Again, specificity and negative predictive values were strong with either method, Dr. Mostafa reported.

“Impaired HbA_1c,” the term used for the values between the two cutoffs (5.6%-6.9%), was found in 59% of the total cohort, who thus required confirmatory tests. Noting that those in the impaired HbA_1c group (55% of the total cohort) had A_1c values between 5.6% and 6.4% (that is, lower than 6.5%), they tried various cut points and arrived at a rule-out value of 5.8% or below and a rule-in value of 6.8% or above. That left 28% of the total cohort in the “impaired HbA_1c” category when defined as an HbA_1c of 5.9%-6.7%.

“We believe [a rule-out value of 5.8% and a rule-in value of 6.8%] would be a more feasible strategy to implement in clinical practice,” Dr. Mostafa said.

These cutoffs gave sensitivities of 92% for white Europeans and 98% for South Asians, and positive predictive values of 70% and 54%, respectively, while maintaining the nearly 100% specificity and negative predictive values for both ethnicities. Despite the slight reductions in positive predictive values, “overall, we feel using the cut points of 5.8% and 6.8% is still diagnostically accurate, with the major advantage that only a quarter of the population would have to return for a subsequent test,” he said.

Dr. Mostafa stated that he had no disclosures.

View on the News

Blood Glucose Tests Are Still Crucial

This study assesses a strategy that I think is quite reasonable, and was suggested in the American Association of Clinical Endocrinologists' position statement a number of months ago.

One must recognize that a “negative” hemoglobin A_1c level (below 6.5%) misses from one-third to one-half of those with diabetes by glucose tolerance test criteria, whereas a “positive” value (6.5% or greater) may not be the result of diabetes in persons who have greater degrees of hemoglobin glycation.

Because high glycation is present in blacks, older populations, and people with iron deficiency, and also is a common variant in the overall population, I would even suggest that blood glucose confirmation – although not necessarily with glucose tolerance testing – should be done in all persons with high HbA_1c, regardless of the level.

Similarly, there are people whose degree of hemoglobin glycation is lower than average. Thus, if there is clinical reason to look for diabetes, it is reasonable to perform glucose tolerance testing even with rather low HbA_1c levels.

Given this inherent variability in glycation, just as the 6.5% diagnostic cutoff is incorrect for many persons whose diabetes status is being ascertained, the use of a specific HbA_1c goal of, say, 6.5% or 7.0%, may not be appropriate for all patients with known diabetes. Again, assessment of actual blood glucose levels is crucial in the management of diabetes.

ZACHARY T. BLOOMGARDEN, M.D., of the Mount Sinai School of Medicine in New York, is on the speakers bureau for Merck, Novo Nordisk, and GlaxoSmithKline; serves on an advisory panel for Merck, Bristol-Myers Squibb, AstraZeneca, Boehringer Ingelheim, and Biodel; is a consultant for Merck, Novartis, Dainippon Sumitomo Pharma America, and Forest Laboratories; and is a stock shareholder of Covidien, C.R. Bard, Novartis, Roche, and Stryker Corp.

STOCKHOLM – Use of a “rule-in” hemoglobin A_1c cut point of 6.8% and a “rule-out” value of 5.8%, with glucose testing for individuals who fall in the middle of the diagnostic cutoff, was more accurate in diagnosing type 2 diabetes than was a single cutoff value of 6.5%.

The finding from a multiethnic cohort study of 8,696 previously undiagnosed primary care patients addresses some of the concerns about false-positive and false-negative diagnoses associated with using a single measure of hemoglobin A_1c. Multiple studies have shown that the 6.5% cutoff may be discordant with the results of an oral glucose tolerance test (OGTT), which is considered to be the standard diagnostic test for type 2 diabetes, said Dr. Samiul A. Mostafa, a clinical research fellow in the diabetes research unit of the University of Leicester (England).

In July 2009, an international expert committee recommended the use of hemoglobin A_1c for diagnosing diabetes, with a diagnostic cutoff of 6.5% or above following a repeat confirmatory A_1c test (Diabetes Care 2009;32:1327-34). In January 2010, the American Diabetes Association endorsed that recommendation (Diabetes Care 2010;33[suppl. 1]:S62-9). The European Association for the Study of Diabetes and the World Health Organization are expected to issue similar statements soon.

The study participants were identified from two systematic screening programs during 2002-2008. Three-quarters (75%) were white Europeans and 23% were South Asians from Pakistan, Bangladesh, and India. The mean HbA_1c for the entire cohort was 5.7%. All underwent an OGTT and also had their HbA_1c levels measured. Using the WHO criteria (a 2-hour plasma glucose level of 200 mg/dL or above, following a 75-g glucose load), the OGTT detected 291 individuals (3.3% of 8,696 study participants) with type 2 diabetes.

Among the white Europeans, use of the 6.5% A_1c cutoff had a sensitivity of 62% and a positive predictive value of 45%. Based on an Australian study published earlier this year, the investigators chose to compare those values with a rule-out A_1c cutoff of 5.5% and a rule-in cutoff of 7.0%, with a confirmatory OGTT used for those falling in between (Diabetes Care 2010;33:817-9).

That method gave an improved sensitivity of 98% and positive predictive value of 76% in the white European group. With either method, specificity and negative predictive values were close to 100%. For the South Asians, the 6.5% cutoff gave a sensitivity of 79% and positive predictive value of 36%, both of which improved to 99% and 68%, respectively, with the two–cut-point criteria. Again, specificity and negative predictive values were strong with either method, Dr. Mostafa reported.

“Impaired HbA_1c,” the term used for the values between the two cutoffs (5.6%-6.9%), was found in 59% of the total cohort, who thus required confirmatory tests. Noting that those in the impaired HbA_1c group (55% of the total cohort) had A_1c values between 5.6% and 6.4% (that is, lower than 6.5%), they tried various cut points and arrived at a rule-out value of 5.8% or below and a rule-in value of 6.8% or above. That left 28% of the total cohort in the “impaired HbA_1c” category when defined as an HbA_1c of 5.9%-6.7%.

“We believe [a rule-out value of 5.8% and a rule-in value of 6.8%] would be a more feasible strategy to implement in clinical practice,” Dr. Mostafa said.

These cutoffs gave sensitivities of 92% for white Europeans and 98% for South Asians, and positive predictive values of 70% and 54%, respectively, while maintaining the nearly 100% specificity and negative predictive values for both ethnicities. Despite the slight reductions in positive predictive values, “overall, we feel using the cut points of 5.8% and 6.8% is still diagnostically accurate, with the major advantage that only a quarter of the population would have to return for a subsequent test,” he said.

Dr. Mostafa stated that he had no disclosures.

View on the News

Blood Glucose Tests Are Still Crucial

This study assesses a strategy that I think is quite reasonable, and was suggested in the American Association of Clinical Endocrinologists' position statement a number of months ago.

One must recognize that a “negative” hemoglobin A_1c level (below 6.5%) misses from one-third to one-half of those with diabetes by glucose tolerance test criteria, whereas a “positive” value (6.5% or greater) may not be the result of diabetes in persons who have greater degrees of hemoglobin glycation.

Because high glycation is present in blacks, older populations, and people with iron deficiency, and also is a common variant in the overall population, I would even suggest that blood glucose confirmation – although not necessarily with glucose tolerance testing – should be done in all persons with high HbA_1c, regardless of the level.

Similarly, there are people whose degree of hemoglobin glycation is lower than average. Thus, if there is clinical reason to look for diabetes, it is reasonable to perform glucose tolerance testing even with rather low HbA_1c levels.

Given this inherent variability in glycation, just as the 6.5% diagnostic cutoff is incorrect for many persons whose diabetes status is being ascertained, the use of a specific HbA_1c goal of, say, 6.5% or 7.0%, may not be appropriate for all patients with known diabetes. Again, assessment of actual blood glucose levels is crucial in the management of diabetes.

ZACHARY T. BLOOMGARDEN, M.D., of the Mount Sinai School of Medicine in New York, is on the speakers bureau for Merck, Novo Nordisk, and GlaxoSmithKline; serves on an advisory panel for Merck, Bristol-Myers Squibb, AstraZeneca, Boehringer Ingelheim, and Biodel; is a consultant for Merck, Novartis, Dainippon Sumitomo Pharma America, and Forest Laboratories; and is a stock shareholder of Covidien, C.R. Bard, Novartis, Roche, and Stryker Corp.

STOCKHOLM – Use of a “rule-in” hemoglobin A_1c cut point of 6.8% and a “rule-out” value of 5.8%, with glucose testing for individuals who fall in the middle of the diagnostic cutoff, was more accurate in diagnosing type 2 diabetes than was a single cutoff value of 6.5%.

The finding from a multiethnic cohort study of 8,696 previously undiagnosed primary care patients addresses some of the concerns about false-positive and false-negative diagnoses associated with using a single measure of hemoglobin A_1c. Multiple studies have shown that the 6.5% cutoff may be discordant with the results of an oral glucose tolerance test (OGTT), which is considered to be the standard diagnostic test for type 2 diabetes, said Dr. Samiul A. Mostafa, a clinical research fellow in the diabetes research unit of the University of Leicester (England).

In July 2009, an international expert committee recommended the use of hemoglobin A_1c for diagnosing diabetes, with a diagnostic cutoff of 6.5% or above following a repeat confirmatory A_1c test (Diabetes Care 2009;32:1327-34). In January 2010, the American Diabetes Association endorsed that recommendation (Diabetes Care 2010;33[suppl. 1]:S62-9). The European Association for the Study of Diabetes and the World Health Organization are expected to issue similar statements soon.

The study participants were identified from two systematic screening programs during 2002-2008. Three-quarters (75%) were white Europeans and 23% were South Asians from Pakistan, Bangladesh, and India. The mean HbA_1c for the entire cohort was 5.7%. All underwent an OGTT and also had their HbA_1c levels measured. Using the WHO criteria (a 2-hour plasma glucose level of 200 mg/dL or above, following a 75-g glucose load), the OGTT detected 291 individuals (3.3% of 8,696 study participants) with type 2 diabetes.

Among the white Europeans, use of the 6.5% A_1c cutoff had a sensitivity of 62% and a positive predictive value of 45%. Based on an Australian study published earlier this year, the investigators chose to compare those values with a rule-out A_1c cutoff of 5.5% and a rule-in cutoff of 7.0%, with a confirmatory OGTT used for those falling in between (Diabetes Care 2010;33:817-9).

That method gave an improved sensitivity of 98% and positive predictive value of 76% in the white European group. With either method, specificity and negative predictive values were close to 100%. For the South Asians, the 6.5% cutoff gave a sensitivity of 79% and positive predictive value of 36%, both of which improved to 99% and 68%, respectively, with the two–cut-point criteria. Again, specificity and negative predictive values were strong with either method, Dr. Mostafa reported.

“Impaired HbA_1c,” the term used for the values between the two cutoffs (5.6%-6.9%), was found in 59% of the total cohort, who thus required confirmatory tests. Noting that those in the impaired HbA_1c group (55% of the total cohort) had A_1c values between 5.6% and 6.4% (that is, lower than 6.5%), they tried various cut points and arrived at a rule-out value of 5.8% or below and a rule-in value of 6.8% or above. That left 28% of the total cohort in the “impaired HbA_1c” category when defined as an HbA_1c of 5.9%-6.7%.

“We believe [a rule-out value of 5.8% and a rule-in value of 6.8%] would be a more feasible strategy to implement in clinical practice,” Dr. Mostafa said.

These cutoffs gave sensitivities of 92% for white Europeans and 98% for South Asians, and positive predictive values of 70% and 54%, respectively, while maintaining the nearly 100% specificity and negative predictive values for both ethnicities. Despite the slight reductions in positive predictive values, “overall, we feel using the cut points of 5.8% and 6.8% is still diagnostically accurate, with the major advantage that only a quarter of the population would have to return for a subsequent test,” he said.

Dr. Mostafa stated that he had no disclosures.

View on the News

Blood Glucose Tests Are Still Crucial

This study assesses a strategy that I think is quite reasonable, and was suggested in the American Association of Clinical Endocrinologists' position statement a number of months ago.

One must recognize that a “negative” hemoglobin A_1c level (below 6.5%) misses from one-third to one-half of those with diabetes by glucose tolerance test criteria, whereas a “positive” value (6.5% or greater) may not be the result of diabetes in persons who have greater degrees of hemoglobin glycation.

Because high glycation is present in blacks, older populations, and people with iron deficiency, and also is a common variant in the overall population, I would even suggest that blood glucose confirmation – although not necessarily with glucose tolerance testing – should be done in all persons with high HbA_1c, regardless of the level.

Similarly, there are people whose degree of hemoglobin glycation is lower than average. Thus, if there is clinical reason to look for diabetes, it is reasonable to perform glucose tolerance testing even with rather low HbA_1c levels.

Given this inherent variability in glycation, just as the 6.5% diagnostic cutoff is incorrect for many persons whose diabetes status is being ascertained, the use of a specific HbA_1c goal of, say, 6.5% or 7.0%, may not be appropriate for all patients with known diabetes. Again, assessment of actual blood glucose levels is crucial in the management of diabetes.

ZACHARY T. BLOOMGARDEN, M.D., of the Mount Sinai School of Medicine in New York, is on the speakers bureau for Merck, Novo Nordisk, and GlaxoSmithKline; serves on an advisory panel for Merck, Bristol-Myers Squibb, AstraZeneca, Boehringer Ingelheim, and Biodel; is a consultant for Merck, Novartis, Dainippon Sumitomo Pharma America, and Forest Laboratories; and is a stock shareholder of Covidien, C.R. Bard, Novartis, Roche, and Stryker Corp.

Major Finding: The cumulative incidence of microalbuminuria was 8.2% of the olmesartan patients vs. 9.8% of the placebo group, for a highly significant risk reduction of 23%.

Data Source: Randomized, placebo-controlled, double-blind, multicenter ROADMAP trial of 4,447 patients with type 2 diabetes and one or more other cardiovascular risk factors but with normoalbuminuria.

Disclosures: The study was funded by Daiichi-Sankyo, which manufactures olmesartan under the name Benicar.

STOCKHOLM – Olmesartan was shown to significantly reduce the time to microalbuminuria in a randomized, placebo-controlled, double-blind multicenter study of 4,447 patients with type 2 diabetes.

The Randomized Olmesartan and Diabetes Microalbuminuria Prevention (ROADMAP) trial investigated whether early treatment with the angiotensin receptor blocker olmesartan would delay the occurrence of microalbuminuria in patients with type 2 diabetes who had at least one other cardiovascular risk factor but who had normal albumin excretion at baseline.

At baseline, the patients had a mean age of 58 years, diabetes duration of 6 years, body mass index of 30 kg/m

Mean blood pressure at baseline was 137/80 mm Hg, and the mean estimated glomerular filtration rate was 85 mL/min per 1.73 m

The patients received 40 mg of olmesartan or placebo once daily for a median of 3.2 years.

In both groups, additional antihypertensive drug treatment other than ARBs or ACE inhibitors was used to reach the target blood pressure of less than 130/80 mm Hg.

That goal was reached by 78% of the olmesartan group and 71% of the placebo group by 48 months, Dr. Hermann Haller reported at the meeting.

The cumulative incidence of microalbuminuria, which was defined as excretion of more than 35 mg albumin/g urine creatinine for women and more than 25 mg albumin/g urine creatinine for men in morning spot urine, was 8.2% of the olmesartan patients vs. 9.8% of the placebo group.

This amounts to a highly significant risk reduction of 23%, said Dr. Haller of Hannover (Germany) Medical School.

Correction for the small differences in blood pressure between the two groups showed that the majority of the effect was blood pressure–independent, he said.

Overall cardiovascular morbidity and mortality rates were low and they were similar between the two groups, with just 4.3% of the olmesartan group and 4.2% of the placebo group experiencing any cardiovascular event or death, Dr. Haller noted.

Total mortality occurred in 1.2% and 1.7%, respectively.

Cardiovascular mortality, however, was higher in the olmesartan group (15 deaths vs. 3 deaths, or 0.7% vs. 0.1%), possibly because of hypotensive episodes among patients with preexisting cardiovascular disease, Dr. Haller said.

There were no adverse effects of olmesartan on hard renal outcomes.

An observational follow-up study is ongoing to further elucidate the long-term benefits of microalbuminuria prevention, Dr. Haller said.

Correction for the small differences in blood pressure between groups showed that most of the effect was BP-independent.

Source DR. HALLER

Major Finding: The cumulative incidence of microalbuminuria was 8.2% of the olmesartan patients vs. 9.8% of the placebo group, for a highly significant risk reduction of 23%.

Data Source: Randomized, placebo-controlled, double-blind, multicenter ROADMAP trial of 4,447 patients with type 2 diabetes and one or more other cardiovascular risk factors but with normoalbuminuria.

Disclosures: The study was funded by Daiichi-Sankyo, which manufactures olmesartan under the name Benicar.

STOCKHOLM – Olmesartan was shown to significantly reduce the time to microalbuminuria in a randomized, placebo-controlled, double-blind multicenter study of 4,447 patients with type 2 diabetes.

The Randomized Olmesartan and Diabetes Microalbuminuria Prevention (ROADMAP) trial investigated whether early treatment with the angiotensin receptor blocker olmesartan would delay the occurrence of microalbuminuria in patients with type 2 diabetes who had at least one other cardiovascular risk factor but who had normal albumin excretion at baseline.

At baseline, the patients had a mean age of 58 years, diabetes duration of 6 years, body mass index of 30 kg/m

Mean blood pressure at baseline was 137/80 mm Hg, and the mean estimated glomerular filtration rate was 85 mL/min per 1.73 m

The patients received 40 mg of olmesartan or placebo once daily for a median of 3.2 years.

In both groups, additional antihypertensive drug treatment other than ARBs or ACE inhibitors was used to reach the target blood pressure of less than 130/80 mm Hg.

That goal was reached by 78% of the olmesartan group and 71% of the placebo group by 48 months, Dr. Hermann Haller reported at the meeting.

The cumulative incidence of microalbuminuria, which was defined as excretion of more than 35 mg albumin/g urine creatinine for women and more than 25 mg albumin/g urine creatinine for men in morning spot urine, was 8.2% of the olmesartan patients vs. 9.8% of the placebo group.

This amounts to a highly significant risk reduction of 23%, said Dr. Haller of Hannover (Germany) Medical School.

Correction for the small differences in blood pressure between the two groups showed that the majority of the effect was blood pressure–independent, he said.

Overall cardiovascular morbidity and mortality rates were low and they were similar between the two groups, with just 4.3% of the olmesartan group and 4.2% of the placebo group experiencing any cardiovascular event or death, Dr. Haller noted.

Total mortality occurred in 1.2% and 1.7%, respectively.

Cardiovascular mortality, however, was higher in the olmesartan group (15 deaths vs. 3 deaths, or 0.7% vs. 0.1%), possibly because of hypotensive episodes among patients with preexisting cardiovascular disease, Dr. Haller said.

There were no adverse effects of olmesartan on hard renal outcomes.

An observational follow-up study is ongoing to further elucidate the long-term benefits of microalbuminuria prevention, Dr. Haller said.

Correction for the small differences in blood pressure between groups showed that most of the effect was BP-independent.

Source DR. HALLER

Major Finding: The cumulative incidence of microalbuminuria was 8.2% of the olmesartan patients vs. 9.8% of the placebo group, for a highly significant risk reduction of 23%.

Data Source: Randomized, placebo-controlled, double-blind, multicenter ROADMAP trial of 4,447 patients with type 2 diabetes and one or more other cardiovascular risk factors but with normoalbuminuria.

Disclosures: The study was funded by Daiichi-Sankyo, which manufactures olmesartan under the name Benicar.

STOCKHOLM – Olmesartan was shown to significantly reduce the time to microalbuminuria in a randomized, placebo-controlled, double-blind multicenter study of 4,447 patients with type 2 diabetes.

The Randomized Olmesartan and Diabetes Microalbuminuria Prevention (ROADMAP) trial investigated whether early treatment with the angiotensin receptor blocker olmesartan would delay the occurrence of microalbuminuria in patients with type 2 diabetes who had at least one other cardiovascular risk factor but who had normal albumin excretion at baseline.

At baseline, the patients had a mean age of 58 years, diabetes duration of 6 years, body mass index of 30 kg/m

Mean blood pressure at baseline was 137/80 mm Hg, and the mean estimated glomerular filtration rate was 85 mL/min per 1.73 m

The patients received 40 mg of olmesartan or placebo once daily for a median of 3.2 years.

In both groups, additional antihypertensive drug treatment other than ARBs or ACE inhibitors was used to reach the target blood pressure of less than 130/80 mm Hg.

That goal was reached by 78% of the olmesartan group and 71% of the placebo group by 48 months, Dr. Hermann Haller reported at the meeting.

The cumulative incidence of microalbuminuria, which was defined as excretion of more than 35 mg albumin/g urine creatinine for women and more than 25 mg albumin/g urine creatinine for men in morning spot urine, was 8.2% of the olmesartan patients vs. 9.8% of the placebo group.

This amounts to a highly significant risk reduction of 23%, said Dr. Haller of Hannover (Germany) Medical School.

Correction for the small differences in blood pressure between the two groups showed that the majority of the effect was blood pressure–independent, he said.

Overall cardiovascular morbidity and mortality rates were low and they were similar between the two groups, with just 4.3% of the olmesartan group and 4.2% of the placebo group experiencing any cardiovascular event or death, Dr. Haller noted.

Total mortality occurred in 1.2% and 1.7%, respectively.

Cardiovascular mortality, however, was higher in the olmesartan group (15 deaths vs. 3 deaths, or 0.7% vs. 0.1%), possibly because of hypotensive episodes among patients with preexisting cardiovascular disease, Dr. Haller said.

There were no adverse effects of olmesartan on hard renal outcomes.

An observational follow-up study is ongoing to further elucidate the long-term benefits of microalbuminuria prevention, Dr. Haller said.

Correction for the small differences in blood pressure between groups showed that most of the effect was BP-independent.

Source DR. HALLER

Over the next 40 years, the total prevalence of diabetes in the United States is expected to increase from its current level of about 1 in 10 adults to as many as 1 in 3 by 2050.

The estimate, which includes both diagnosed and undiagnosed diabetes, comes from a new statistical modeling of data from the 2000 Census and the Centers for Disease Control and Prevention (CDC). The projected increase in diabetes prevalence is attributed to the aging of the U.S. population, increasing size of higher-risk minority populations, and declining mortality among people with diabetes, said Dr. James P. Boyle and his associates, of the CDC's Division of Diabetes Translation and Emory University, Atlanta.

“Our estimates of diabetes prevalence paint a sobering picture of the future growth of diabetes …. The projected loss in quality of life and the projected costs of providing health care could be significant. Increased efforts in primary prevention of diabetes can help to decrease loss in quality of life and the future cost of providing care for people with diabetes,” the investigators said in their paper, published in the journal Population Health Metrics.

Previous projections of the prevalence, incidence, and total number of diabetes cases in the United States are outdated because they relied on 1990 census projections, which overestimated current mortality rates and did not account for the increasing size of the Hispanic and foreign-born U.S. populations at higher risk for diabetes.

In contrast, the current analysis included 2000 Census–based estimates of the 2007 population and estimates of mortality rates, births, and migration from 2008 through 2050, along with CDC data on diabetes incidence rates among adults aged 18-79 years during 1980-2007.

Models were based on historical incidence of newly diagnosed diabetes per 1,000 persons from 1980 through 2007, with “low” incidence being the 2.5th percentile and “high” incidence defined as the 97.5th percentile. Historically, the incidence of diabetes in the U.S. ranged from 3 cases per 1,000 population in 1980 to 8 per 1,000 in 2007. The “middle incidence” scenario—reflecting recent rate increases—projects an increase of 8 cases per 1,000 in 2008 to 15 cases per 1,000 in 2050.

According to the estimated projection, the prevalence of diagnosed or undiagnosed diabetes would increase from 14% in 2010 to 25% in 2050 under a low incidence/low mortality risk scenario, 21% with low incidence/high mortality, 33% with middle incidence/low mortality risk and 28% for middle incidence/high mortality.

Assuming a hypothetical intervention such as universal lifestyle modification reaching 100% of those at high risk for diabetes (that is, those with impaired fasting glucose), the annual incidence of diabetes would still be reduced only by 25%.

“Our analysis suggests that widespread implementation of reasonably effective preventive interventions focused on high-risk subgroups of the population may not eliminate, but might considerably reduce, future increases in diabetes prevalence,” Dr. Boyle and his associates noted.

The authors declared that they have no competing interests.

Over the next 40 years, the total prevalence of diabetes in the United States is expected to increase from its current level of about 1 in 10 adults to as many as 1 in 3 by 2050.

The estimate, which includes both diagnosed and undiagnosed diabetes, comes from a new statistical modeling of data from the 2000 Census and the Centers for Disease Control and Prevention (CDC). The projected increase in diabetes prevalence is attributed to the aging of the U.S. population, increasing size of higher-risk minority populations, and declining mortality among people with diabetes, said Dr. James P. Boyle and his associates, of the CDC's Division of Diabetes Translation and Emory University, Atlanta.

“Our estimates of diabetes prevalence paint a sobering picture of the future growth of diabetes …. The projected loss in quality of life and the projected costs of providing health care could be significant. Increased efforts in primary prevention of diabetes can help to decrease loss in quality of life and the future cost of providing care for people with diabetes,” the investigators said in their paper, published in the journal Population Health Metrics.

Previous projections of the prevalence, incidence, and total number of diabetes cases in the United States are outdated because they relied on 1990 census projections, which overestimated current mortality rates and did not account for the increasing size of the Hispanic and foreign-born U.S. populations at higher risk for diabetes.

In contrast, the current analysis included 2000 Census–based estimates of the 2007 population and estimates of mortality rates, births, and migration from 2008 through 2050, along with CDC data on diabetes incidence rates among adults aged 18-79 years during 1980-2007.

Models were based on historical incidence of newly diagnosed diabetes per 1,000 persons from 1980 through 2007, with “low” incidence being the 2.5th percentile and “high” incidence defined as the 97.5th percentile. Historically, the incidence of diabetes in the U.S. ranged from 3 cases per 1,000 population in 1980 to 8 per 1,000 in 2007. The “middle incidence” scenario—reflecting recent rate increases—projects an increase of 8 cases per 1,000 in 2008 to 15 cases per 1,000 in 2050.

According to the estimated projection, the prevalence of diagnosed or undiagnosed diabetes would increase from 14% in 2010 to 25% in 2050 under a low incidence/low mortality risk scenario, 21% with low incidence/high mortality, 33% with middle incidence/low mortality risk and 28% for middle incidence/high mortality.

Assuming a hypothetical intervention such as universal lifestyle modification reaching 100% of those at high risk for diabetes (that is, those with impaired fasting glucose), the annual incidence of diabetes would still be reduced only by 25%.

“Our analysis suggests that widespread implementation of reasonably effective preventive interventions focused on high-risk subgroups of the population may not eliminate, but might considerably reduce, future increases in diabetes prevalence,” Dr. Boyle and his associates noted.

The authors declared that they have no competing interests.

Over the next 40 years, the total prevalence of diabetes in the United States is expected to increase from its current level of about 1 in 10 adults to as many as 1 in 3 by 2050.

The estimate, which includes both diagnosed and undiagnosed diabetes, comes from a new statistical modeling of data from the 2000 Census and the Centers for Disease Control and Prevention (CDC). The projected increase in diabetes prevalence is attributed to the aging of the U.S. population, increasing size of higher-risk minority populations, and declining mortality among people with diabetes, said Dr. James P. Boyle and his associates, of the CDC's Division of Diabetes Translation and Emory University, Atlanta.

“Our estimates of diabetes prevalence paint a sobering picture of the future growth of diabetes …. The projected loss in quality of life and the projected costs of providing health care could be significant. Increased efforts in primary prevention of diabetes can help to decrease loss in quality of life and the future cost of providing care for people with diabetes,” the investigators said in their paper, published in the journal Population Health Metrics.

Previous projections of the prevalence, incidence, and total number of diabetes cases in the United States are outdated because they relied on 1990 census projections, which overestimated current mortality rates and did not account for the increasing size of the Hispanic and foreign-born U.S. populations at higher risk for diabetes.

In contrast, the current analysis included 2000 Census–based estimates of the 2007 population and estimates of mortality rates, births, and migration from 2008 through 2050, along with CDC data on diabetes incidence rates among adults aged 18-79 years during 1980-2007.

Models were based on historical incidence of newly diagnosed diabetes per 1,000 persons from 1980 through 2007, with “low” incidence being the 2.5th percentile and “high” incidence defined as the 97.5th percentile. Historically, the incidence of diabetes in the U.S. ranged from 3 cases per 1,000 population in 1980 to 8 per 1,000 in 2007. The “middle incidence” scenario—reflecting recent rate increases—projects an increase of 8 cases per 1,000 in 2008 to 15 cases per 1,000 in 2050.

According to the estimated projection, the prevalence of diagnosed or undiagnosed diabetes would increase from 14% in 2010 to 25% in 2050 under a low incidence/low mortality risk scenario, 21% with low incidence/high mortality, 33% with middle incidence/low mortality risk and 28% for middle incidence/high mortality.

Assuming a hypothetical intervention such as universal lifestyle modification reaching 100% of those at high risk for diabetes (that is, those with impaired fasting glucose), the annual incidence of diabetes would still be reduced only by 25%.

“Our analysis suggests that widespread implementation of reasonably effective preventive interventions focused on high-risk subgroups of the population may not eliminate, but might considerably reduce, future increases in diabetes prevalence,” Dr. Boyle and his associates noted.

The authors declared that they have no competing interests.

STOCKHOLM – The risk for developing type 2 diabetes is not the same for everyone with metabolic syndrome, but instead varies dramatically depending on individual factors.

In fact, hyperglycemia – with or without metabolic syndrome – was a much stronger predictor of incident type 2 diabetes than was metabolic syndrome without hyperglycemia in a 5-year observational analysis of 58,056 initially nondiabetic adults aged 30 years and older who were members of the managed care organization Kaiser Permanente Northwest, Gregory A. Nichols, Ph.D., said.

“In the absence of impaired fasting glucose, the definition of metabolic syndrome may be a misleading estimator of diabetes risk,” according to Dr. Nichols, who was the lead investigator on the study (Diabetes Res. Clin. Pract. 2010;90:115-21).

He and a colleague examined the incidence of diabetes for all possible combinations of metabolic syndrome components using criteria defined in the National Cholesterol Education Program's Adult Treatment Panel III report (ATP III) (Circulation 2004;109:433-8).

The one exception was the use of body mass index as a substitute for waist circumference, which is rarely measured clinically, explained Dr. Nichols of Kaiser Permanente's Center for Health Research, Portland, Ore.

For the study, an individual was considered to have metabolic syndrome if they met three of the following five criteria:

▸ Impaired fasting glucose (greater than 100 mg/dL),

▸ Hypertension (130/85 mm Hg or greater),

▸ High triglycerides (150 mg/dL or greater),

▸ Low HDL cholesterol (less than 40 mg/dL for men, 50 mg/dL for women), and

▸ Body mass index greater than 28.8 kg/m

Over 5 years, 6% of the total study sample developed diabetes. Compared with those who did not develop diabetes, those who did were significantly older (59 vs. 57 years), and were more likely to be male (52% vs. 44%), non-white (10% vs. 8%) and a current smoker (15% vs. 12%).

Not surprisingly, the risk for developing diabetes was greater in the presence than in the absence of each individual component. The 5-year risk for diabetes rose with each component an individual had at baseline, from 0.3% for those with none to 1.2% with one, 3.5% with two, 8.4% with three, 16.9% with four, and 28.2% with five.

However, the risk for diabetes varied dramatically among the five individual components. The greatest risk was associated with impaired fasting glucose (IFG), with an incidence of 37.4/1,000 person-years.

Low HDL cholesterol was next (21.6/1,000 person-years), followed by high triglycerides (20.6/1,000), obesity (19.5), and hypertension (16.2).

There was a clear separation between combinations of components that did and did not contain IFG. The combination of IFG and any one additional component – by definition, not meeting metabolic syndrome criteria – had a higher incidence rate of diabetes (16.5/1,000 person-years) than did any three- or four-component combination that did not include IFG (7.9 and 11.3 per 1,000 person-years, respectively), yet did meet the metabolic syndrome criteria.

The incidence of diabetes among those who had IFG and no other metabolic syndrome component was 10.2/1,000 person-years, just slightly less than the incidence for those with every component except IFG (11.3/1,000), Dr. Nichols reported.

“Better prediction tools that identify truly high-risk individuals would enhance diabetes prevention strategies,” he concluded at the meeting.

In the published article, Dr. Nichols and his coauthor Dr. Edward J. Moler noted that in addition to the association with diabetes, the clustering of risk factors that comprise metabolic syndrome also are precursors to cardiovascular disease (CVD), and that the relationship of individual components to CVD is unclear.

“Because metabolic syndrome is also used to predict CVD risk, future research should assess the relative importance of metabolic syndrome components to predict incident CVD,” they said.

STOCKHOLM – The risk for developing type 2 diabetes is not the same for everyone with metabolic syndrome, but instead varies dramatically depending on individual factors.

In fact, hyperglycemia – with or without metabolic syndrome – was a much stronger predictor of incident type 2 diabetes than was metabolic syndrome without hyperglycemia in a 5-year observational analysis of 58,056 initially nondiabetic adults aged 30 years and older who were members of the managed care organization Kaiser Permanente Northwest, Gregory A. Nichols, Ph.D., said.

“In the absence of impaired fasting glucose, the definition of metabolic syndrome may be a misleading estimator of diabetes risk,” according to Dr. Nichols, who was the lead investigator on the study (Diabetes Res. Clin. Pract. 2010;90:115-21).

He and a colleague examined the incidence of diabetes for all possible combinations of metabolic syndrome components using criteria defined in the National Cholesterol Education Program's Adult Treatment Panel III report (ATP III) (Circulation 2004;109:433-8).

The one exception was the use of body mass index as a substitute for waist circumference, which is rarely measured clinically, explained Dr. Nichols of Kaiser Permanente's Center for Health Research, Portland, Ore.

For the study, an individual was considered to have metabolic syndrome if they met three of the following five criteria:

▸ Impaired fasting glucose (greater than 100 mg/dL),

▸ Hypertension (130/85 mm Hg or greater),

▸ High triglycerides (150 mg/dL or greater),

▸ Low HDL cholesterol (less than 40 mg/dL for men, 50 mg/dL for women), and

▸ Body mass index greater than 28.8 kg/m

Over 5 years, 6% of the total study sample developed diabetes. Compared with those who did not develop diabetes, those who did were significantly older (59 vs. 57 years), and were more likely to be male (52% vs. 44%), non-white (10% vs. 8%) and a current smoker (15% vs. 12%).

Not surprisingly, the risk for developing diabetes was greater in the presence than in the absence of each individual component. The 5-year risk for diabetes rose with each component an individual had at baseline, from 0.3% for those with none to 1.2% with one, 3.5% with two, 8.4% with three, 16.9% with four, and 28.2% with five.

However, the risk for diabetes varied dramatically among the five individual components. The greatest risk was associated with impaired fasting glucose (IFG), with an incidence of 37.4/1,000 person-years.

Low HDL cholesterol was next (21.6/1,000 person-years), followed by high triglycerides (20.6/1,000), obesity (19.5), and hypertension (16.2).

There was a clear separation between combinations of components that did and did not contain IFG. The combination of IFG and any one additional component – by definition, not meeting metabolic syndrome criteria – had a higher incidence rate of diabetes (16.5/1,000 person-years) than did any three- or four-component combination that did not include IFG (7.9 and 11.3 per 1,000 person-years, respectively), yet did meet the metabolic syndrome criteria.

The incidence of diabetes among those who had IFG and no other metabolic syndrome component was 10.2/1,000 person-years, just slightly less than the incidence for those with every component except IFG (11.3/1,000), Dr. Nichols reported.

“Better prediction tools that identify truly high-risk individuals would enhance diabetes prevention strategies,” he concluded at the meeting.

In the published article, Dr. Nichols and his coauthor Dr. Edward J. Moler noted that in addition to the association with diabetes, the clustering of risk factors that comprise metabolic syndrome also are precursors to cardiovascular disease (CVD), and that the relationship of individual components to CVD is unclear.

“Because metabolic syndrome is also used to predict CVD risk, future research should assess the relative importance of metabolic syndrome components to predict incident CVD,” they said.

STOCKHOLM – The risk for developing type 2 diabetes is not the same for everyone with metabolic syndrome, but instead varies dramatically depending on individual factors.

In fact, hyperglycemia – with or without metabolic syndrome – was a much stronger predictor of incident type 2 diabetes than was metabolic syndrome without hyperglycemia in a 5-year observational analysis of 58,056 initially nondiabetic adults aged 30 years and older who were members of the managed care organization Kaiser Permanente Northwest, Gregory A. Nichols, Ph.D., said.

“In the absence of impaired fasting glucose, the definition of metabolic syndrome may be a misleading estimator of diabetes risk,” according to Dr. Nichols, who was the lead investigator on the study (Diabetes Res. Clin. Pract. 2010;90:115-21).

He and a colleague examined the incidence of diabetes for all possible combinations of metabolic syndrome components using criteria defined in the National Cholesterol Education Program's Adult Treatment Panel III report (ATP III) (Circulation 2004;109:433-8).

The one exception was the use of body mass index as a substitute for waist circumference, which is rarely measured clinically, explained Dr. Nichols of Kaiser Permanente's Center for Health Research, Portland, Ore.

For the study, an individual was considered to have metabolic syndrome if they met three of the following five criteria:

▸ Impaired fasting glucose (greater than 100 mg/dL),

▸ Hypertension (130/85 mm Hg or greater),

▸ High triglycerides (150 mg/dL or greater),

▸ Low HDL cholesterol (less than 40 mg/dL for men, 50 mg/dL for women), and

▸ Body mass index greater than 28.8 kg/m

Over 5 years, 6% of the total study sample developed diabetes. Compared with those who did not develop diabetes, those who did were significantly older (59 vs. 57 years), and were more likely to be male (52% vs. 44%), non-white (10% vs. 8%) and a current smoker (15% vs. 12%).

Not surprisingly, the risk for developing diabetes was greater in the presence than in the absence of each individual component. The 5-year risk for diabetes rose with each component an individual had at baseline, from 0.3% for those with none to 1.2% with one, 3.5% with two, 8.4% with three, 16.9% with four, and 28.2% with five.

However, the risk for diabetes varied dramatically among the five individual components. The greatest risk was associated with impaired fasting glucose (IFG), with an incidence of 37.4/1,000 person-years.

Low HDL cholesterol was next (21.6/1,000 person-years), followed by high triglycerides (20.6/1,000), obesity (19.5), and hypertension (16.2).

There was a clear separation between combinations of components that did and did not contain IFG. The combination of IFG and any one additional component – by definition, not meeting metabolic syndrome criteria – had a higher incidence rate of diabetes (16.5/1,000 person-years) than did any three- or four-component combination that did not include IFG (7.9 and 11.3 per 1,000 person-years, respectively), yet did meet the metabolic syndrome criteria.

The incidence of diabetes among those who had IFG and no other metabolic syndrome component was 10.2/1,000 person-years, just slightly less than the incidence for those with every component except IFG (11.3/1,000), Dr. Nichols reported.

“Better prediction tools that identify truly high-risk individuals would enhance diabetes prevention strategies,” he concluded at the meeting.

In the published article, Dr. Nichols and his coauthor Dr. Edward J. Moler noted that in addition to the association with diabetes, the clustering of risk factors that comprise metabolic syndrome also are precursors to cardiovascular disease (CVD), and that the relationship of individual components to CVD is unclear.

“Because metabolic syndrome is also used to predict CVD risk, future research should assess the relative importance of metabolic syndrome components to predict incident CVD,” they said.

ATLANTA – In the face of an ongoing pertussis outbreak in California, a series of three votes by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices aimed to expand and clarify recommendations for pertussis vaccination.

The votes taken at the meeting removed previous language restricting the interval for receipt of the adolescent-adult formulation of the tetanus-diphtheria-pertussis vaccine, and expanded the use of Tdap to adults aged 65 years and older and to undervaccinated children aged 7-10 years.

Kathleen Harriman, Ph.D., of the California Department of Public Health's Immunization Branch updated the committee on the California outbreak. A total of 6,978 cases had been reported as of Oct. 19, 2010, for a rate of 16 cases per 100,000 population. Ten deaths have been reported among infants aged 2 months or younger.

The California state health department has recommended Tdap for all individuals aged 10 years and older who have not yet received it – particularly women of childbearing age (including those who are pregnant), others who have contact with young infants, and individuals older than 64 years of age – and also as a replacement for the old tetanus-diphtheria (Td) vaccine for wound management, even though the vaccine is not licensed for those aged 7-9 years or 64 years and older.

The state also said that Tdap should be given without regard to the interval since the previous Td dose, said Dr. Harriman, who is also a registered nurse.

Dr. Jennifer Liang of the CDC's National Center for Immunization and Respiratory Diseases (NCIRD) presented similar draft document language for the ACIP to vote on.

In 2005, the ACIP adolescent recommendation (for those aged 11-12 years) had said that an interval of at least 5 years between Td and Tdap was “encouraged” to reduce the risk for local and systemic reactions, particularly the limb swelling that – although usually benign – can be frightening for parents.

The new language, unanimously approved by ACIP (with one abstention), says that adolescents aged 11-18 years who have completed the recommended five-dose childhood diphtheria and tetanus toxoids and whole-cell pertussis vaccine (DTP)/diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) vaccination series and adults age 19-64 years should receive a single dose of Tdap in place of one Td dose. Adolescents should receive Tdap at a preventive care visit at 11-12 years of age, Dr. Liang said.

In addition, adolescents or adults who have not received a dose of Tdap – or for whom the status is unknown – should be immunized as soon as feasible, regardless of the interval since the last tetanus- or diphtheria-containing vaccine.

The second vote, to recommend Tdap for adults aged 65 years and older, was taken following presentations by Dr. Wayde Weston of GlaxoSmithKline and Dr. Michael Decker of Sanofi Pasteur, demonstrating immunogenicity and safety of Boostrix and Adacel, respectively, in adults aged 64 and older. GSK has filed an application with the Food and Drug Administration for an indication in that age group; Sanofi Pasteur is working on its application.

The recommendation says that adults aged 65 years and older who have or who anticipate having close contact with an infant aged younger than 12 months (such as a grandparent, child care provider, or health care provider) should receive a single dose of Tdap to protect against pertussis and to reduce the likelihood of transmission of pertussis to infants aged younger than 12 months (who are not yet fully immunized).

In addition, for adults aged 65 and older, a single dose of Tdap vaccine may be given in place of a Td vaccine in those who have not previously received Tdap.

Finally, the committee voted another off-label use of Tdap in children aged 7-10 years with incomplete or unknown pertussis vaccine history.

For those children, a single dose of Tdap is recommended to protect against pertussis. If further doses of tetanus- and diphtheria-containing vaccines are needed, then children aged 7-10 years should be vaccinated according to catch-up guidance.

Further guidance is forthcoming regarding revaccination.

Children aged 7-10 years who have never been vaccinated against tetanus, diphtheria, or pertussis or who have unknown vaccine status should receive a series of three vaccinations containing tetanus and diphtheria toxoids. The preferred schedule is a single dose of Tdap, followed by a dose of Td more than 4 weeks after Tdap and another dose of Td 6-12 months later. If not given as the first dose, Tdap can be substituted for any of the other Td doses in the series.

Although the California pertussis outbreak has raised the urgency of these recommendations, the ACIP has actually been working on increasing pertussis immunization for at least 2 years, working group chair Dr. Mark H. Sawyer said in an interview.

“The main idea of all of this is to free up people's ability to receive vaccine in special circumstances, such as an outbreak. … But this was already on our agenda. Pertussis has been a recognized problem for some time now. The California outbreak just illuminated its importance. But it's not unique to California. Other states are having significant problems with pertussis,” said Dr. Sawyer, professor of pediatrics at the University of California, San Diego.

As a CDC employee, Dr. Liang has no financial conflicts. Dr. Harriman and Dr. Sawyer also stated that they had no financial conflicts.

ATLANTA – In the face of an ongoing pertussis outbreak in California, a series of three votes by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices aimed to expand and clarify recommendations for pertussis vaccination.

The votes taken at the meeting removed previous language restricting the interval for receipt of the adolescent-adult formulation of the tetanus-diphtheria-pertussis vaccine, and expanded the use of Tdap to adults aged 65 years and older and to undervaccinated children aged 7-10 years.

Kathleen Harriman, Ph.D., of the California Department of Public Health's Immunization Branch updated the committee on the California outbreak. A total of 6,978 cases had been reported as of Oct. 19, 2010, for a rate of 16 cases per 100,000 population. Ten deaths have been reported among infants aged 2 months or younger.

The California state health department has recommended Tdap for all individuals aged 10 years and older who have not yet received it – particularly women of childbearing age (including those who are pregnant), others who have contact with young infants, and individuals older than 64 years of age – and also as a replacement for the old tetanus-diphtheria (Td) vaccine for wound management, even though the vaccine is not licensed for those aged 7-9 years or 64 years and older.

The state also said that Tdap should be given without regard to the interval since the previous Td dose, said Dr. Harriman, who is also a registered nurse.

Dr. Jennifer Liang of the CDC's National Center for Immunization and Respiratory Diseases (NCIRD) presented similar draft document language for the ACIP to vote on.

In 2005, the ACIP adolescent recommendation (for those aged 11-12 years) had said that an interval of at least 5 years between Td and Tdap was “encouraged” to reduce the risk for local and systemic reactions, particularly the limb swelling that – although usually benign – can be frightening for parents.

The new language, unanimously approved by ACIP (with one abstention), says that adolescents aged 11-18 years who have completed the recommended five-dose childhood diphtheria and tetanus toxoids and whole-cell pertussis vaccine (DTP)/diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) vaccination series and adults age 19-64 years should receive a single dose of Tdap in place of one Td dose. Adolescents should receive Tdap at a preventive care visit at 11-12 years of age, Dr. Liang said.

In addition, adolescents or adults who have not received a dose of Tdap – or for whom the status is unknown – should be immunized as soon as feasible, regardless of the interval since the last tetanus- or diphtheria-containing vaccine.

The second vote, to recommend Tdap for adults aged 65 years and older, was taken following presentations by Dr. Wayde Weston of GlaxoSmithKline and Dr. Michael Decker of Sanofi Pasteur, demonstrating immunogenicity and safety of Boostrix and Adacel, respectively, in adults aged 64 and older. GSK has filed an application with the Food and Drug Administration for an indication in that age group; Sanofi Pasteur is working on its application.

The recommendation says that adults aged 65 years and older who have or who anticipate having close contact with an infant aged younger than 12 months (such as a grandparent, child care provider, or health care provider) should receive a single dose of Tdap to protect against pertussis and to reduce the likelihood of transmission of pertussis to infants aged younger than 12 months (who are not yet fully immunized).

In addition, for adults aged 65 and older, a single dose of Tdap vaccine may be given in place of a Td vaccine in those who have not previously received Tdap.

Finally, the committee voted another off-label use of Tdap in children aged 7-10 years with incomplete or unknown pertussis vaccine history.

For those children, a single dose of Tdap is recommended to protect against pertussis. If further doses of tetanus- and diphtheria-containing vaccines are needed, then children aged 7-10 years should be vaccinated according to catch-up guidance.

Further guidance is forthcoming regarding revaccination.

Children aged 7-10 years who have never been vaccinated against tetanus, diphtheria, or pertussis or who have unknown vaccine status should receive a series of three vaccinations containing tetanus and diphtheria toxoids. The preferred schedule is a single dose of Tdap, followed by a dose of Td more than 4 weeks after Tdap and another dose of Td 6-12 months later. If not given as the first dose, Tdap can be substituted for any of the other Td doses in the series.

Although the California pertussis outbreak has raised the urgency of these recommendations, the ACIP has actually been working on increasing pertussis immunization for at least 2 years, working group chair Dr. Mark H. Sawyer said in an interview.

“The main idea of all of this is to free up people's ability to receive vaccine in special circumstances, such as an outbreak. … But this was already on our agenda. Pertussis has been a recognized problem for some time now. The California outbreak just illuminated its importance. But it's not unique to California. Other states are having significant problems with pertussis,” said Dr. Sawyer, professor of pediatrics at the University of California, San Diego.

As a CDC employee, Dr. Liang has no financial conflicts. Dr. Harriman and Dr. Sawyer also stated that they had no financial conflicts.

ATLANTA – In the face of an ongoing pertussis outbreak in California, a series of three votes by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices aimed to expand and clarify recommendations for pertussis vaccination.

The votes taken at the meeting removed previous language restricting the interval for receipt of the adolescent-adult formulation of the tetanus-diphtheria-pertussis vaccine, and expanded the use of Tdap to adults aged 65 years and older and to undervaccinated children aged 7-10 years.

Kathleen Harriman, Ph.D., of the California Department of Public Health's Immunization Branch updated the committee on the California outbreak. A total of 6,978 cases had been reported as of Oct. 19, 2010, for a rate of 16 cases per 100,000 population. Ten deaths have been reported among infants aged 2 months or younger.

The California state health department has recommended Tdap for all individuals aged 10 years and older who have not yet received it – particularly women of childbearing age (including those who are pregnant), others who have contact with young infants, and individuals older than 64 years of age – and also as a replacement for the old tetanus-diphtheria (Td) vaccine for wound management, even though the vaccine is not licensed for those aged 7-9 years or 64 years and older.

The state also said that Tdap should be given without regard to the interval since the previous Td dose, said Dr. Harriman, who is also a registered nurse.

Dr. Jennifer Liang of the CDC's National Center for Immunization and Respiratory Diseases (NCIRD) presented similar draft document language for the ACIP to vote on.

In 2005, the ACIP adolescent recommendation (for those aged 11-12 years) had said that an interval of at least 5 years between Td and Tdap was “encouraged” to reduce the risk for local and systemic reactions, particularly the limb swelling that – although usually benign – can be frightening for parents.

The new language, unanimously approved by ACIP (with one abstention), says that adolescents aged 11-18 years who have completed the recommended five-dose childhood diphtheria and tetanus toxoids and whole-cell pertussis vaccine (DTP)/diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) vaccination series and adults age 19-64 years should receive a single dose of Tdap in place of one Td dose. Adolescents should receive Tdap at a preventive care visit at 11-12 years of age, Dr. Liang said.

In addition, adolescents or adults who have not received a dose of Tdap – or for whom the status is unknown – should be immunized as soon as feasible, regardless of the interval since the last tetanus- or diphtheria-containing vaccine.

The second vote, to recommend Tdap for adults aged 65 years and older, was taken following presentations by Dr. Wayde Weston of GlaxoSmithKline and Dr. Michael Decker of Sanofi Pasteur, demonstrating immunogenicity and safety of Boostrix and Adacel, respectively, in adults aged 64 and older. GSK has filed an application with the Food and Drug Administration for an indication in that age group; Sanofi Pasteur is working on its application.

The recommendation says that adults aged 65 years and older who have or who anticipate having close contact with an infant aged younger than 12 months (such as a grandparent, child care provider, or health care provider) should receive a single dose of Tdap to protect against pertussis and to reduce the likelihood of transmission of pertussis to infants aged younger than 12 months (who are not yet fully immunized).

In addition, for adults aged 65 and older, a single dose of Tdap vaccine may be given in place of a Td vaccine in those who have not previously received Tdap.

Finally, the committee voted another off-label use of Tdap in children aged 7-10 years with incomplete or unknown pertussis vaccine history.

For those children, a single dose of Tdap is recommended to protect against pertussis. If further doses of tetanus- and diphtheria-containing vaccines are needed, then children aged 7-10 years should be vaccinated according to catch-up guidance.

Further guidance is forthcoming regarding revaccination.

Children aged 7-10 years who have never been vaccinated against tetanus, diphtheria, or pertussis or who have unknown vaccine status should receive a series of three vaccinations containing tetanus and diphtheria toxoids. The preferred schedule is a single dose of Tdap, followed by a dose of Td more than 4 weeks after Tdap and another dose of Td 6-12 months later. If not given as the first dose, Tdap can be substituted for any of the other Td doses in the series.

Although the California pertussis outbreak has raised the urgency of these recommendations, the ACIP has actually been working on increasing pertussis immunization for at least 2 years, working group chair Dr. Mark H. Sawyer said in an interview.

“The main idea of all of this is to free up people's ability to receive vaccine in special circumstances, such as an outbreak. … But this was already on our agenda. Pertussis has been a recognized problem for some time now. The California outbreak just illuminated its importance. But it's not unique to California. Other states are having significant problems with pertussis,” said Dr. Sawyer, professor of pediatrics at the University of California, San Diego.

As a CDC employee, Dr. Liang has no financial conflicts. Dr. Harriman and Dr. Sawyer also stated that they had no financial conflicts.