Practice Alert

The Centers for Disease Control and Prevention (CDC) has made 2 significant changes to its annual recommendations for the prevention of influenza during the 2008-2009 flu season:¹

1. Annual vaccination is now recommended for all children ages 6 months through 18 years. (Last year, universal influenza vaccination was recommended only for children ages 6 months through 4 years.)
2. The live attenuated influenza vaccine (LAIV) can now be used starting at 2 years of age.

Vaccinate older children

The CDC now recommends that 5- to 18-year-olds receive the influenza vaccine annually, and that this routine vaccination start as soon as possible, but no later than the 2009-2010 flu season. In other words, if routine vaccination can be achieved this year it is encouraged, but the CDC recognizes that it may not be possible to achieve in some settings until next year.

If family physicians do not incorporate routine vaccination for those ages 5 to 18 this year, they should still provide it for those in this age group who are at high risk for influenza complications, including those who:

• are on long-term aspirin therapy;
• have chronic pulmonary (including asthma), cardiovascular, renal, hepatic, hematological, or metabolic disorders;
• are immunosuppressed; or
• have disorders that alter respiratory functions or the handling of respiratory secretions.

Children who live in households with others who are at higher risk (children who are <5 years old, adults >50 years, and anyone with a medical condition that places him or her at high risk for severe influenza complications) should also be vaccinated.

LAIV is an option for even younger kids

Last year, the LAIV vaccine was licensed for children starting at age 5. Now, the LAIV can be given to healthy children starting at age 2, as well as to adolescents and adults through age 49. TABLE 1 compares the LAIV with the trivalent influenza vaccine (TIV).

Because LAIV is an attenuated live virus vaccine, some children should not receive it, including those younger than 5 years of age with reactive airway disease (recurrent wheezing or recent wheezing); those with a medical condition that places them at high risk of influenza complications; and those younger than 2 years of age. The TIV can be used in these children, starting at 6 months of age.

Regardless of whether a child receives LAIV or TIV, those younger than 9 years of age who are receiving influenza vaccine for the first time should receive 2 doses 4 weeks apart. If a child received only 1 dose in the first year, the following year he or she should receive 2 doses 4 weeks apart.

TABLE 1
LAIV vs TIV: How the 2 compare

Coverage rates still need to improve

Influenza vaccine and antiviral agents continue to be underutilized. TABLE 2 lists estimated coverage with influenza vaccine for specific groups for whom immunization is recommended. It is particularly important that coverage rates for health care workers—which remain below 50%—be improved. Health care workers are at high risk of exposure to influenza and pose a risk of disease transmission to their families, other staff members, and patients. Family physicians should ensure that they and their staff are vaccinated each year.

Missed opportunities. Many patients for whom influenza vaccine is recommended fail to receive the vaccine because of missed opportunities. Physicians should offer the vaccine starting in October (or as soon as the vaccine supply allows) and continue to offer and encourage it through the entire flu season. Peak influenza activity can occur as late as April and May and occurs after February on average of 1 in every 5 years.

TABLE 2
Immunization is recommended, but what were the coverage rates?*

Autism concerns persist among parents

Despite clear scientific evidence that neither vaccines nor thimerosal preservative cause autism, some parents remain concerned. Some states have passed laws prohibiting the use of any thimerosal-containing vaccines and some parents may request thimerosal-free vaccines. TABLE 3 lists all the influenza vaccines and their thimerosal content.

TABLE 3
Which vaccines contain thimerosal—and how much?

Make use of antivirals

Two antiviral medications are licensed and approved for the treatment and prevention of influenza: oseltamivir (Tamiflu) and zanamivir (Relenza). Two others (amantadine and rimantadine) are licensed but not currently recommended due to the high rates of resistance that influenza has developed against them.

Oseltamivir is approved for the treatment and prophylaxis of influenza starting at 1 year of age.

Zanamivir is approved for the treatment of influenza starting at 7 years of age and for prophylaxis starting at 5 years of age.

Treatment, if started within 48 hours of symptom onset, reduces the severity and length of infection and the length of infectiousness. Antiviral prophylaxis should be considered when there is increased influenza activity for those listed in TABLE 4.

TABLE 4
Increased flu activity in the community? Consider antiviral prophylaxis

Every bit helps

Each year, influenza kills, on average, 36,000 Americans and hospitalizes another 200,000. Much of this morbidity and mortality could be avoided with full utilization of influenza vaccines and antiviral medications. You can contribute to improved public health by assuring that your patients and staff are fully immunized, that office infection control practices are adhered to, and that antiviral prophylaxis is used when indicated.

The Centers for Disease Control and Prevention (CDC) has made 2 significant changes to its annual recommendations for the prevention of influenza during the 2008-2009 flu season:¹

1. Annual vaccination is now recommended for all children ages 6 months through 18 years. (Last year, universal influenza vaccination was recommended only for children ages 6 months through 4 years.)
2. The live attenuated influenza vaccine (LAIV) can now be used starting at 2 years of age.

Vaccinate older children

The CDC now recommends that 5- to 18-year-olds receive the influenza vaccine annually, and that this routine vaccination start as soon as possible, but no later than the 2009-2010 flu season. In other words, if routine vaccination can be achieved this year it is encouraged, but the CDC recognizes that it may not be possible to achieve in some settings until next year.

If family physicians do not incorporate routine vaccination for those ages 5 to 18 this year, they should still provide it for those in this age group who are at high risk for influenza complications, including those who:

• are on long-term aspirin therapy;
• have chronic pulmonary (including asthma), cardiovascular, renal, hepatic, hematological, or metabolic disorders;
• are immunosuppressed; or
• have disorders that alter respiratory functions or the handling of respiratory secretions.

Children who live in households with others who are at higher risk (children who are <5 years old, adults >50 years, and anyone with a medical condition that places him or her at high risk for severe influenza complications) should also be vaccinated.

LAIV is an option for even younger kids

Last year, the LAIV vaccine was licensed for children starting at age 5. Now, the LAIV can be given to healthy children starting at age 2, as well as to adolescents and adults through age 49. TABLE 1 compares the LAIV with the trivalent influenza vaccine (TIV).

Because LAIV is an attenuated live virus vaccine, some children should not receive it, including those younger than 5 years of age with reactive airway disease (recurrent wheezing or recent wheezing); those with a medical condition that places them at high risk of influenza complications; and those younger than 2 years of age. The TIV can be used in these children, starting at 6 months of age.

Regardless of whether a child receives LAIV or TIV, those younger than 9 years of age who are receiving influenza vaccine for the first time should receive 2 doses 4 weeks apart. If a child received only 1 dose in the first year, the following year he or she should receive 2 doses 4 weeks apart.

TABLE 1
LAIV vs TIV: How the 2 compare

Coverage rates still need to improve

Influenza vaccine and antiviral agents continue to be underutilized. TABLE 2 lists estimated coverage with influenza vaccine for specific groups for whom immunization is recommended. It is particularly important that coverage rates for health care workers—which remain below 50%—be improved. Health care workers are at high risk of exposure to influenza and pose a risk of disease transmission to their families, other staff members, and patients. Family physicians should ensure that they and their staff are vaccinated each year.

Missed opportunities. Many patients for whom influenza vaccine is recommended fail to receive the vaccine because of missed opportunities. Physicians should offer the vaccine starting in October (or as soon as the vaccine supply allows) and continue to offer and encourage it through the entire flu season. Peak influenza activity can occur as late as April and May and occurs after February on average of 1 in every 5 years.

TABLE 2
Immunization is recommended, but what were the coverage rates?*

Autism concerns persist among parents

Despite clear scientific evidence that neither vaccines nor thimerosal preservative cause autism, some parents remain concerned. Some states have passed laws prohibiting the use of any thimerosal-containing vaccines and some parents may request thimerosal-free vaccines. TABLE 3 lists all the influenza vaccines and their thimerosal content.

TABLE 3
Which vaccines contain thimerosal—and how much?

Make use of antivirals

Two antiviral medications are licensed and approved for the treatment and prevention of influenza: oseltamivir (Tamiflu) and zanamivir (Relenza). Two others (amantadine and rimantadine) are licensed but not currently recommended due to the high rates of resistance that influenza has developed against them.

Oseltamivir is approved for the treatment and prophylaxis of influenza starting at 1 year of age.

Zanamivir is approved for the treatment of influenza starting at 7 years of age and for prophylaxis starting at 5 years of age.

Treatment, if started within 48 hours of symptom onset, reduces the severity and length of infection and the length of infectiousness. Antiviral prophylaxis should be considered when there is increased influenza activity for those listed in TABLE 4.

TABLE 4
Increased flu activity in the community? Consider antiviral prophylaxis

Every bit helps

Each year, influenza kills, on average, 36,000 Americans and hospitalizes another 200,000. Much of this morbidity and mortality could be avoided with full utilization of influenza vaccines and antiviral medications. You can contribute to improved public health by assuring that your patients and staff are fully immunized, that office infection control practices are adhered to, and that antiviral prophylaxis is used when indicated.

The Centers for Disease Control and Prevention (CDC) has made 2 significant changes to its annual recommendations for the prevention of influenza during the 2008-2009 flu season:¹

1. Annual vaccination is now recommended for all children ages 6 months through 18 years. (Last year, universal influenza vaccination was recommended only for children ages 6 months through 4 years.)
2. The live attenuated influenza vaccine (LAIV) can now be used starting at 2 years of age.

Vaccinate older children

The CDC now recommends that 5- to 18-year-olds receive the influenza vaccine annually, and that this routine vaccination start as soon as possible, but no later than the 2009-2010 flu season. In other words, if routine vaccination can be achieved this year it is encouraged, but the CDC recognizes that it may not be possible to achieve in some settings until next year.

If family physicians do not incorporate routine vaccination for those ages 5 to 18 this year, they should still provide it for those in this age group who are at high risk for influenza complications, including those who:

• are on long-term aspirin therapy;
• have chronic pulmonary (including asthma), cardiovascular, renal, hepatic, hematological, or metabolic disorders;
• are immunosuppressed; or
• have disorders that alter respiratory functions or the handling of respiratory secretions.

Children who live in households with others who are at higher risk (children who are <5 years old, adults >50 years, and anyone with a medical condition that places him or her at high risk for severe influenza complications) should also be vaccinated.

LAIV is an option for even younger kids

Last year, the LAIV vaccine was licensed for children starting at age 5. Now, the LAIV can be given to healthy children starting at age 2, as well as to adolescents and adults through age 49. TABLE 1 compares the LAIV with the trivalent influenza vaccine (TIV).

Because LAIV is an attenuated live virus vaccine, some children should not receive it, including those younger than 5 years of age with reactive airway disease (recurrent wheezing or recent wheezing); those with a medical condition that places them at high risk of influenza complications; and those younger than 2 years of age. The TIV can be used in these children, starting at 6 months of age.

Regardless of whether a child receives LAIV or TIV, those younger than 9 years of age who are receiving influenza vaccine for the first time should receive 2 doses 4 weeks apart. If a child received only 1 dose in the first year, the following year he or she should receive 2 doses 4 weeks apart.

TABLE 1
LAIV vs TIV: How the 2 compare

Coverage rates still need to improve

Influenza vaccine and antiviral agents continue to be underutilized. TABLE 2 lists estimated coverage with influenza vaccine for specific groups for whom immunization is recommended. It is particularly important that coverage rates for health care workers—which remain below 50%—be improved. Health care workers are at high risk of exposure to influenza and pose a risk of disease transmission to their families, other staff members, and patients. Family physicians should ensure that they and their staff are vaccinated each year.

Missed opportunities. Many patients for whom influenza vaccine is recommended fail to receive the vaccine because of missed opportunities. Physicians should offer the vaccine starting in October (or as soon as the vaccine supply allows) and continue to offer and encourage it through the entire flu season. Peak influenza activity can occur as late as April and May and occurs after February on average of 1 in every 5 years.

TABLE 2
Immunization is recommended, but what were the coverage rates?*

Autism concerns persist among parents

Despite clear scientific evidence that neither vaccines nor thimerosal preservative cause autism, some parents remain concerned. Some states have passed laws prohibiting the use of any thimerosal-containing vaccines and some parents may request thimerosal-free vaccines. TABLE 3 lists all the influenza vaccines and their thimerosal content.

TABLE 3
Which vaccines contain thimerosal—and how much?

Make use of antivirals

Two antiviral medications are licensed and approved for the treatment and prevention of influenza: oseltamivir (Tamiflu) and zanamivir (Relenza). Two others (amantadine and rimantadine) are licensed but not currently recommended due to the high rates of resistance that influenza has developed against them.

Oseltamivir is approved for the treatment and prophylaxis of influenza starting at 1 year of age.

Zanamivir is approved for the treatment of influenza starting at 7 years of age and for prophylaxis starting at 5 years of age.

Treatment, if started within 48 hours of symptom onset, reduces the severity and length of infection and the length of infectiousness. Antiviral prophylaxis should be considered when there is increased influenza activity for those listed in TABLE 4.

TABLE 4
Increased flu activity in the community? Consider antiviral prophylaxis

Every bit helps

Each year, influenza kills, on average, 36,000 Americans and hospitalizes another 200,000. Much of this morbidity and mortality could be avoided with full utilization of influenza vaccines and antiviral medications. You can contribute to improved public health by assuring that your patients and staff are fully immunized, that office infection control practices are adhered to, and that antiviral prophylaxis is used when indicated.

Not enough time and too many potential tests to do. This is the problem faced daily by family physicians. We want to practice up-to-date preventive medicine, but there’s little time to analyze the latest studies. Thankfully, we can rely on the United States Preventive Services Task Force, the organization with the most rigorous evidence-based approach, to do the legwork for us.¹

Last year, and in the early part of this year, the Task Force issued a number of recommendations on topics ranging from hypertension screening to screening for illicit drug use. (See TABLE 1 for a breakdown of the 5 categories of recommendations.)

While some of these recommendations (TABLE 2) were reaffirmations of past recommendations, others included some changes.

The Task Force has:

• dropped the age for routine screening for Chlamydia in sexually active women from 25 years and younger to 24 and younger.
• added a recommendation against the use of aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs) to prevent colorectal cancer (CRC).
• changed its recommendation on screening for carotid artery stenosis. In 1996, the Task Force noted that the evidence was insufficient to make a recommendation; in 2007 it recommended against such routine screening.
• added recommendations on counseling patients about drinking and driving, as well as on screening for illicit drug use. In both cases, the Task Force says the evidence is insufficient to recommend for or against.

TABLE 1
USPSTF recommendation categories

TABLE 2
Summary of new USPSTF recommendations

Continue to screen for HTN, sickle cell, Chlamydia

The latest A and B recommendations from the Task Force largely reaffirm previous recommendations. These recommendations cover hypertension, sickle cell disease, and Chlamydia.

Hypertension. Screening and treatment of hypertension in adults leads to lower morbidity and mortality from cardiovascular disease and is still recommended.²

Sickle cell disease. Screening newborns for sickle cell disease and treating those affected with oral prophylactic penicillin prevents serious bacterial infections. It also remains a recommended service.³

Chlamydia. Following a review of the evidence, the Task Force reconfirms the benefits of screening for Chlamydia in sexually active young women, but it has changed the age cutoff. In 2001, the Task Force indicated that sexually active women who were 25 years of age and younger should be screened. In 2007, the Task Force dropped the age to 24 and younger.

The latest recommendation reaffirms the need to screen women (above the cutoff) who are at risk—that is, women who have previously had a sexually transmitted infection (STI), those who have a new or multiple sex partners, and those who exchange sex for money or drugs.⁴ Screening is recommended annually; nucleic acid amplification tests are acceptable, allowing testing of urine or vaginal swabs.

Screening during pregnancy is recommended for the same groups—women who are 24 and younger and older women at risk—at the first prenatal visit and again in the third trimester if risk continues. Chlamydia is the most common bacterial STI, and screening and treatment prevents pelvic inflammatory disease in women and leads to improved pregnancy outcomes.

Interventions that are not recommended

Chemopreventon of colorectal cancer. For the first time, the Task Force issued a recommendation on the use of aspirin or other NSAIDs to prevent CRC. The Task Force does not recommend the routine use of these agents.⁵ The dosage needed to prevent CRC is higher than that which prevents cardiovascular disease and can cause significant harm.

Aspirin use is associated with gastrointestinal bleeding and hemorrhagic stroke; NSAID use is associated with gastrointestinal bleeding and renal impairment. The Task Force concludes that in the general adult population, potential harms exceed potential benefits.

Screening for carotid artery stenosis. In 1996, the Task Force found insufficient evidence to recommend for or against routine screening for carotid artery stenosis. In 2007, the Task Force made a recommendation against routine screening for carotid artery stenosis.⁶ Screening with duplex ultrasonography results in frequent false positives. Confirmatory testing with angiography is associated with a 1% rate of stroke. Endarterectomy itself has a death or stroke rate of about 3%.

In the general population, close to 8700 adults would need to be screened to prevent 1 disabling stroke. The Task Force indicates that primary care physicians would have better outcomes by concentrating on optimal management of risk factors for cerebral artery disease.

Screening for bacterial vaginosis among low-risk pregnant women. The final D recommendation pertains to screening for bacterial vaginosis during pregnancy to prevent preterm delivery.⁷ Pregnant women who have not had a previous preterm delivery are considered at low risk for preterm delivery and there is good evidence that this group does not benefit from screening for, or treatment of, asymptomatic bacterial vaginosis. (A similar recommendation was made in 2001, but it referred to women of “average” risk.)

Insufficient evidence to make a recommendation

Routinely screening men for Chlamydia. While it makes clinical sense to test and treat male partners of women with Chlamydia infection, the Task Force could not find evidence of the effectiveness of routinely screening men as a way to prevent infection in women.⁴ That said, the Task Force points out that screening men is relatively inexpensive and has negligible harms.

Screening for hyperlipidemia in children. While 50% of children with hyperlipidemia continue to have this disorder as adults, the long-term benefits and harms of early detection and treatment with medications and lipid-lowering diets have not been studied.⁸ This echoes the position the Task Force took in 1996, when it commented on children as part of an adult hyperlipidemia recommendation.

Physician counseling on drinking and driving. Motor vehicle crashes result in significant morbidity and mortality—especially among adolescents and young adults. Improved car and road design, as well as public health safety efforts, have led to significant improvements in motor vehicle safety. While avoidance of driving under the influence and proper use of occupant restraints are important public health goals, the Task Force, in this first recommendation on the subject, could find no evidence that physician counseling added benefit above those provided by community-wide efforts.⁹

Screening for bacterial vaginosis in pregnant women at high risk for preterm birth. As mentioned previously, screening low-risk pregnant women for bacterial vaginosis results in no benefit. The issue is less clear cut among women at high risk for a preterm delivery—that is, those who have had one previously.

The evidence regarding screening and treating asymptomatic bacterial vaginosis as a means of preventing preterm delivery in these women is mixed and the Task Force was unable to recommend for or against this practice.⁷ This reaffirms the Task Force’s 2001 recommendation.

Screening for illicit drug use. The Task Force recognizes that illicit drug use is a major cause of illness and social problems. It would appear to have great potential for early detection and intervention. However, the Task Force, in this first-time recommendation, found that screening tools have not been well studied, nor have the long-term effects of different treatment strategies.¹⁰ These are high priority areas for future research.

Correspondence
Doug Campos-Outcalt, MD, MPA, 550 E. Van Buren, Phoenix, AZ 85004; [email protected]

Not enough time and too many potential tests to do. This is the problem faced daily by family physicians. We want to practice up-to-date preventive medicine, but there’s little time to analyze the latest studies. Thankfully, we can rely on the United States Preventive Services Task Force, the organization with the most rigorous evidence-based approach, to do the legwork for us.¹

Last year, and in the early part of this year, the Task Force issued a number of recommendations on topics ranging from hypertension screening to screening for illicit drug use. (See TABLE 1 for a breakdown of the 5 categories of recommendations.)

While some of these recommendations (TABLE 2) were reaffirmations of past recommendations, others included some changes.

The Task Force has:

• dropped the age for routine screening for Chlamydia in sexually active women from 25 years and younger to 24 and younger.
• added a recommendation against the use of aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs) to prevent colorectal cancer (CRC).
• changed its recommendation on screening for carotid artery stenosis. In 1996, the Task Force noted that the evidence was insufficient to make a recommendation; in 2007 it recommended against such routine screening.
• added recommendations on counseling patients about drinking and driving, as well as on screening for illicit drug use. In both cases, the Task Force says the evidence is insufficient to recommend for or against.

TABLE 1
USPSTF recommendation categories

TABLE 2
Summary of new USPSTF recommendations

Continue to screen for HTN, sickle cell, Chlamydia

The latest A and B recommendations from the Task Force largely reaffirm previous recommendations. These recommendations cover hypertension, sickle cell disease, and Chlamydia.

Hypertension. Screening and treatment of hypertension in adults leads to lower morbidity and mortality from cardiovascular disease and is still recommended.²

Sickle cell disease. Screening newborns for sickle cell disease and treating those affected with oral prophylactic penicillin prevents serious bacterial infections. It also remains a recommended service.³

Chlamydia. Following a review of the evidence, the Task Force reconfirms the benefits of screening for Chlamydia in sexually active young women, but it has changed the age cutoff. In 2001, the Task Force indicated that sexually active women who were 25 years of age and younger should be screened. In 2007, the Task Force dropped the age to 24 and younger.

The latest recommendation reaffirms the need to screen women (above the cutoff) who are at risk—that is, women who have previously had a sexually transmitted infection (STI), those who have a new or multiple sex partners, and those who exchange sex for money or drugs.⁴ Screening is recommended annually; nucleic acid amplification tests are acceptable, allowing testing of urine or vaginal swabs.

Screening during pregnancy is recommended for the same groups—women who are 24 and younger and older women at risk—at the first prenatal visit and again in the third trimester if risk continues. Chlamydia is the most common bacterial STI, and screening and treatment prevents pelvic inflammatory disease in women and leads to improved pregnancy outcomes.

Interventions that are not recommended

Chemopreventon of colorectal cancer. For the first time, the Task Force issued a recommendation on the use of aspirin or other NSAIDs to prevent CRC. The Task Force does not recommend the routine use of these agents.⁵ The dosage needed to prevent CRC is higher than that which prevents cardiovascular disease and can cause significant harm.

Aspirin use is associated with gastrointestinal bleeding and hemorrhagic stroke; NSAID use is associated with gastrointestinal bleeding and renal impairment. The Task Force concludes that in the general adult population, potential harms exceed potential benefits.

Screening for carotid artery stenosis. In 1996, the Task Force found insufficient evidence to recommend for or against routine screening for carotid artery stenosis. In 2007, the Task Force made a recommendation against routine screening for carotid artery stenosis.⁶ Screening with duplex ultrasonography results in frequent false positives. Confirmatory testing with angiography is associated with a 1% rate of stroke. Endarterectomy itself has a death or stroke rate of about 3%.

In the general population, close to 8700 adults would need to be screened to prevent 1 disabling stroke. The Task Force indicates that primary care physicians would have better outcomes by concentrating on optimal management of risk factors for cerebral artery disease.

Screening for bacterial vaginosis among low-risk pregnant women. The final D recommendation pertains to screening for bacterial vaginosis during pregnancy to prevent preterm delivery.⁷ Pregnant women who have not had a previous preterm delivery are considered at low risk for preterm delivery and there is good evidence that this group does not benefit from screening for, or treatment of, asymptomatic bacterial vaginosis. (A similar recommendation was made in 2001, but it referred to women of “average” risk.)

Insufficient evidence to make a recommendation

Routinely screening men for Chlamydia. While it makes clinical sense to test and treat male partners of women with Chlamydia infection, the Task Force could not find evidence of the effectiveness of routinely screening men as a way to prevent infection in women.⁴ That said, the Task Force points out that screening men is relatively inexpensive and has negligible harms.

Screening for hyperlipidemia in children. While 50% of children with hyperlipidemia continue to have this disorder as adults, the long-term benefits and harms of early detection and treatment with medications and lipid-lowering diets have not been studied.⁸ This echoes the position the Task Force took in 1996, when it commented on children as part of an adult hyperlipidemia recommendation.

Physician counseling on drinking and driving. Motor vehicle crashes result in significant morbidity and mortality—especially among adolescents and young adults. Improved car and road design, as well as public health safety efforts, have led to significant improvements in motor vehicle safety. While avoidance of driving under the influence and proper use of occupant restraints are important public health goals, the Task Force, in this first recommendation on the subject, could find no evidence that physician counseling added benefit above those provided by community-wide efforts.⁹

Screening for bacterial vaginosis in pregnant women at high risk for preterm birth. As mentioned previously, screening low-risk pregnant women for bacterial vaginosis results in no benefit. The issue is less clear cut among women at high risk for a preterm delivery—that is, those who have had one previously.

The evidence regarding screening and treating asymptomatic bacterial vaginosis as a means of preventing preterm delivery in these women is mixed and the Task Force was unable to recommend for or against this practice.⁷ This reaffirms the Task Force’s 2001 recommendation.

Screening for illicit drug use. The Task Force recognizes that illicit drug use is a major cause of illness and social problems. It would appear to have great potential for early detection and intervention. However, the Task Force, in this first-time recommendation, found that screening tools have not been well studied, nor have the long-term effects of different treatment strategies.¹⁰ These are high priority areas for future research.

Correspondence
Doug Campos-Outcalt, MD, MPA, 550 E. Van Buren, Phoenix, AZ 85004; [email protected]

Not enough time and too many potential tests to do. This is the problem faced daily by family physicians. We want to practice up-to-date preventive medicine, but there’s little time to analyze the latest studies. Thankfully, we can rely on the United States Preventive Services Task Force, the organization with the most rigorous evidence-based approach, to do the legwork for us.¹

Last year, and in the early part of this year, the Task Force issued a number of recommendations on topics ranging from hypertension screening to screening for illicit drug use. (See TABLE 1 for a breakdown of the 5 categories of recommendations.)

While some of these recommendations (TABLE 2) were reaffirmations of past recommendations, others included some changes.

The Task Force has:

• dropped the age for routine screening for Chlamydia in sexually active women from 25 years and younger to 24 and younger.
• added a recommendation against the use of aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs) to prevent colorectal cancer (CRC).
• changed its recommendation on screening for carotid artery stenosis. In 1996, the Task Force noted that the evidence was insufficient to make a recommendation; in 2007 it recommended against such routine screening.
• added recommendations on counseling patients about drinking and driving, as well as on screening for illicit drug use. In both cases, the Task Force says the evidence is insufficient to recommend for or against.

TABLE 1
USPSTF recommendation categories

TABLE 2
Summary of new USPSTF recommendations

Continue to screen for HTN, sickle cell, Chlamydia

The latest A and B recommendations from the Task Force largely reaffirm previous recommendations. These recommendations cover hypertension, sickle cell disease, and Chlamydia.

Hypertension. Screening and treatment of hypertension in adults leads to lower morbidity and mortality from cardiovascular disease and is still recommended.²

Sickle cell disease. Screening newborns for sickle cell disease and treating those affected with oral prophylactic penicillin prevents serious bacterial infections. It also remains a recommended service.³

Chlamydia. Following a review of the evidence, the Task Force reconfirms the benefits of screening for Chlamydia in sexually active young women, but it has changed the age cutoff. In 2001, the Task Force indicated that sexually active women who were 25 years of age and younger should be screened. In 2007, the Task Force dropped the age to 24 and younger.

The latest recommendation reaffirms the need to screen women (above the cutoff) who are at risk—that is, women who have previously had a sexually transmitted infection (STI), those who have a new or multiple sex partners, and those who exchange sex for money or drugs.⁴ Screening is recommended annually; nucleic acid amplification tests are acceptable, allowing testing of urine or vaginal swabs.

Screening during pregnancy is recommended for the same groups—women who are 24 and younger and older women at risk—at the first prenatal visit and again in the third trimester if risk continues. Chlamydia is the most common bacterial STI, and screening and treatment prevents pelvic inflammatory disease in women and leads to improved pregnancy outcomes.

Interventions that are not recommended

Chemopreventon of colorectal cancer. For the first time, the Task Force issued a recommendation on the use of aspirin or other NSAIDs to prevent CRC. The Task Force does not recommend the routine use of these agents.⁵ The dosage needed to prevent CRC is higher than that which prevents cardiovascular disease and can cause significant harm.

Aspirin use is associated with gastrointestinal bleeding and hemorrhagic stroke; NSAID use is associated with gastrointestinal bleeding and renal impairment. The Task Force concludes that in the general adult population, potential harms exceed potential benefits.

Screening for carotid artery stenosis. In 1996, the Task Force found insufficient evidence to recommend for or against routine screening for carotid artery stenosis. In 2007, the Task Force made a recommendation against routine screening for carotid artery stenosis.⁶ Screening with duplex ultrasonography results in frequent false positives. Confirmatory testing with angiography is associated with a 1% rate of stroke. Endarterectomy itself has a death or stroke rate of about 3%.

In the general population, close to 8700 adults would need to be screened to prevent 1 disabling stroke. The Task Force indicates that primary care physicians would have better outcomes by concentrating on optimal management of risk factors for cerebral artery disease.

Screening for bacterial vaginosis among low-risk pregnant women. The final D recommendation pertains to screening for bacterial vaginosis during pregnancy to prevent preterm delivery.⁷ Pregnant women who have not had a previous preterm delivery are considered at low risk for preterm delivery and there is good evidence that this group does not benefit from screening for, or treatment of, asymptomatic bacterial vaginosis. (A similar recommendation was made in 2001, but it referred to women of “average” risk.)

Insufficient evidence to make a recommendation

Routinely screening men for Chlamydia. While it makes clinical sense to test and treat male partners of women with Chlamydia infection, the Task Force could not find evidence of the effectiveness of routinely screening men as a way to prevent infection in women.⁴ That said, the Task Force points out that screening men is relatively inexpensive and has negligible harms.

Screening for hyperlipidemia in children. While 50% of children with hyperlipidemia continue to have this disorder as adults, the long-term benefits and harms of early detection and treatment with medications and lipid-lowering diets have not been studied.⁸ This echoes the position the Task Force took in 1996, when it commented on children as part of an adult hyperlipidemia recommendation.

Physician counseling on drinking and driving. Motor vehicle crashes result in significant morbidity and mortality—especially among adolescents and young adults. Improved car and road design, as well as public health safety efforts, have led to significant improvements in motor vehicle safety. While avoidance of driving under the influence and proper use of occupant restraints are important public health goals, the Task Force, in this first recommendation on the subject, could find no evidence that physician counseling added benefit above those provided by community-wide efforts.⁹

Screening for bacterial vaginosis in pregnant women at high risk for preterm birth. As mentioned previously, screening low-risk pregnant women for bacterial vaginosis results in no benefit. The issue is less clear cut among women at high risk for a preterm delivery—that is, those who have had one previously.

The evidence regarding screening and treating asymptomatic bacterial vaginosis as a means of preventing preterm delivery in these women is mixed and the Task Force was unable to recommend for or against this practice.⁷ This reaffirms the Task Force’s 2001 recommendation.

Screening for illicit drug use. The Task Force recognizes that illicit drug use is a major cause of illness and social problems. It would appear to have great potential for early detection and intervention. However, the Task Force, in this first-time recommendation, found that screening tools have not been well studied, nor have the long-term effects of different treatment strategies.¹⁰ These are high priority areas for future research.

Correspondence
Doug Campos-Outcalt, MD, MPA, 550 E. Van Buren, Phoenix, AZ 85004; [email protected]

Measles is still a threat. Endemic transmission of measles no longer occurs in the United States (or any of the Americas), yet this highly infectious disease is still a threat from importation by visitors from other countries and from US residents who have traveled abroad. Two recent outbreaks (described at left) illustrate these risks.

What the CDC discovered

The 2 outbreaks of import-linked measles brought home—literally—the sobering facts about vulnerability among US residents. The CDC report ^1,2 of its investigation observed:

US travelers can be exposed almost anywhere, developed countries included. The California outbreak started with a visit to Switzerland.

Measles spreads rapidly in susceptible subgroups, unless effective control strategies are used. In California, on 2 consecutive days, 5 school children and 4 children in a doctor’s office were infected; all were unvaccinated.

People not considered at risk can contract measles. Although 2 doses of vaccine are 99% effective, vaccinated individuals, such as the college students, can contract measles. Likewise, people born before 1957 may not be immune, in contrast to the general definition of immunity (see Measles Basics. Case in point: the airline passenger, born in 1954.

Disease can be severe. The 40-year-old salesperson (no documented vaccination) was hospitalized with seizure, 105ºF fever, and pneumonia. One of the infants was hospitalized due to dehydration.

People in routine contact with travelers entering the United States can be exposed to measles—like the airline worker.

Take-home lessons for family physicians

Include measles in the differential diagnosis of patients who have fever and rash, especially if they have traveled to another country within the past 3 to 4 weeks. Any patient who meets the definition of measles (fever 101ºF or higher; rash; and at least 1 of the 3 Cs—cough, coryza, conjunctivitis) should be immediately reported to the local health department. The health department will provide instructions for collecting laboratory samples for confirmation; instructions on patient isolation; and assistance with notification and disease control measures for exposed individuals.

Immunize patients and staff. These recurring cases of imported measles underscore the importance of maintaining a high level of immunity. Outbreaks can happen even where immunity is 90% to 95%. When vaccination rates dip below 90%, sustained outbreaks can occur.⁶

Ensure that staff and patients are all immunized against vaccine-preventable diseases, and inform concerned parents about the safety and effectiveness of vaccines. Parents who refuse to have their children vaccinated place their children at risk and contribute to higher community risk. Communities that have higher rates of non-adherence to vaccine recommendations are more likely to have outbreaks.^7,8

Use strict infection control in the office. The recent outbreak in California where 4 children were infected in their physician’s office reinforces the need for strict infection-control practices. Do not allow patients with rash and fever to remain in a common waiting area. Move them to an examination room, preferably an airborne infection isolation room. Keep the door to the examination room closed, and be sure that all health care personnel who come in contact with such patients are immune. Do not use triage rooms for 2 hours after the patient suspected of having measles leaves. Do not send these patients to other health care facilities, such as laboratories, unless infection control measures can be adhered to at those locations. Guidelines on infection control practices in health care settings are available.^9,10

Quick response

Quick control of these outbreaks shows the value of the public health infrastructure. Disease surveillance and outbreak response is vital to the public health system, and its value is frequently under-appreciated by physicians and the public.

Measles is still a threat. Endemic transmission of measles no longer occurs in the United States (or any of the Americas), yet this highly infectious disease is still a threat from importation by visitors from other countries and from US residents who have traveled abroad. Two recent outbreaks (described at left) illustrate these risks.

What the CDC discovered

The 2 outbreaks of import-linked measles brought home—literally—the sobering facts about vulnerability among US residents. The CDC report ^1,2 of its investigation observed:

US travelers can be exposed almost anywhere, developed countries included. The California outbreak started with a visit to Switzerland.

Measles spreads rapidly in susceptible subgroups, unless effective control strategies are used. In California, on 2 consecutive days, 5 school children and 4 children in a doctor’s office were infected; all were unvaccinated.

People not considered at risk can contract measles. Although 2 doses of vaccine are 99% effective, vaccinated individuals, such as the college students, can contract measles. Likewise, people born before 1957 may not be immune, in contrast to the general definition of immunity (see Measles Basics. Case in point: the airline passenger, born in 1954.

Disease can be severe. The 40-year-old salesperson (no documented vaccination) was hospitalized with seizure, 105ºF fever, and pneumonia. One of the infants was hospitalized due to dehydration.

People in routine contact with travelers entering the United States can be exposed to measles—like the airline worker.

Take-home lessons for family physicians

Include measles in the differential diagnosis of patients who have fever and rash, especially if they have traveled to another country within the past 3 to 4 weeks. Any patient who meets the definition of measles (fever 101ºF or higher; rash; and at least 1 of the 3 Cs—cough, coryza, conjunctivitis) should be immediately reported to the local health department. The health department will provide instructions for collecting laboratory samples for confirmation; instructions on patient isolation; and assistance with notification and disease control measures for exposed individuals.

Immunize patients and staff. These recurring cases of imported measles underscore the importance of maintaining a high level of immunity. Outbreaks can happen even where immunity is 90% to 95%. When vaccination rates dip below 90%, sustained outbreaks can occur.⁶

Ensure that staff and patients are all immunized against vaccine-preventable diseases, and inform concerned parents about the safety and effectiveness of vaccines. Parents who refuse to have their children vaccinated place their children at risk and contribute to higher community risk. Communities that have higher rates of non-adherence to vaccine recommendations are more likely to have outbreaks.^7,8

Use strict infection control in the office. The recent outbreak in California where 4 children were infected in their physician’s office reinforces the need for strict infection-control practices. Do not allow patients with rash and fever to remain in a common waiting area. Move them to an examination room, preferably an airborne infection isolation room. Keep the door to the examination room closed, and be sure that all health care personnel who come in contact with such patients are immune. Do not use triage rooms for 2 hours after the patient suspected of having measles leaves. Do not send these patients to other health care facilities, such as laboratories, unless infection control measures can be adhered to at those locations. Guidelines on infection control practices in health care settings are available.^9,10

Quick response

Quick control of these outbreaks shows the value of the public health infrastructure. Disease surveillance and outbreak response is vital to the public health system, and its value is frequently under-appreciated by physicians and the public.

Measles is still a threat. Endemic transmission of measles no longer occurs in the United States (or any of the Americas), yet this highly infectious disease is still a threat from importation by visitors from other countries and from US residents who have traveled abroad. Two recent outbreaks (described at left) illustrate these risks.

What the CDC discovered

The 2 outbreaks of import-linked measles brought home—literally—the sobering facts about vulnerability among US residents. The CDC report ^1,2 of its investigation observed:

US travelers can be exposed almost anywhere, developed countries included. The California outbreak started with a visit to Switzerland.

Measles spreads rapidly in susceptible subgroups, unless effective control strategies are used. In California, on 2 consecutive days, 5 school children and 4 children in a doctor’s office were infected; all were unvaccinated.

People not considered at risk can contract measles. Although 2 doses of vaccine are 99% effective, vaccinated individuals, such as the college students, can contract measles. Likewise, people born before 1957 may not be immune, in contrast to the general definition of immunity (see Measles Basics. Case in point: the airline passenger, born in 1954.

Disease can be severe. The 40-year-old salesperson (no documented vaccination) was hospitalized with seizure, 105ºF fever, and pneumonia. One of the infants was hospitalized due to dehydration.

People in routine contact with travelers entering the United States can be exposed to measles—like the airline worker.

Take-home lessons for family physicians

Include measles in the differential diagnosis of patients who have fever and rash, especially if they have traveled to another country within the past 3 to 4 weeks. Any patient who meets the definition of measles (fever 101ºF or higher; rash; and at least 1 of the 3 Cs—cough, coryza, conjunctivitis) should be immediately reported to the local health department. The health department will provide instructions for collecting laboratory samples for confirmation; instructions on patient isolation; and assistance with notification and disease control measures for exposed individuals.

Immunize patients and staff. These recurring cases of imported measles underscore the importance of maintaining a high level of immunity. Outbreaks can happen even where immunity is 90% to 95%. When vaccination rates dip below 90%, sustained outbreaks can occur.⁶

Ensure that staff and patients are all immunized against vaccine-preventable diseases, and inform concerned parents about the safety and effectiveness of vaccines. Parents who refuse to have their children vaccinated place their children at risk and contribute to higher community risk. Communities that have higher rates of non-adherence to vaccine recommendations are more likely to have outbreaks.^7,8

Use strict infection control in the office. The recent outbreak in California where 4 children were infected in their physician’s office reinforces the need for strict infection-control practices. Do not allow patients with rash and fever to remain in a common waiting area. Move them to an examination room, preferably an airborne infection isolation room. Keep the door to the examination room closed, and be sure that all health care personnel who come in contact with such patients are immune. Do not use triage rooms for 2 hours after the patient suspected of having measles leaves. Do not send these patients to other health care facilities, such as laboratories, unless infection control measures can be adhered to at those locations. Guidelines on infection control practices in health care settings are available.^9,10

Quick response

Quick control of these outbreaks shows the value of the public health infrastructure. Disease surveillance and outbreak response is vital to the public health system, and its value is frequently under-appreciated by physicians and the public.

The year 2007 was rather calm, compared to the 3 previous years in regards to new vaccines and vaccine recommendations. Although no breakthrough vaccine products came onto the market in 2007, there were new recommendations and licensure for new age groups for existing vaccines and a recall of some lots of Hib vaccines.

Meningococcal vaccine

Recommendations on the use of the quadrivalent meningococcal conjugate vaccine (MCV4) have evolved since its licensure in 2005 for use in persons 11 to 55 years of age. The first set of recommendations focused on universal vaccination of preteens, aged 11 to 12, those entering high school who had not received the vaccine previously, and others at risk for meningococcal disease including college freshmen living in dormitories.¹ The MCV4 was preferred to the older polysaccharide vaccine (MPSV4) which was recommended only for children aged 2 to 10 and adults over age 55 at increased risk.

In 2007, the CDC changed 2 of the 2005 recommendations:

• The first, in August, simplified the recommendations for teens, making MCV4 universally recommended for all those aged 11 to 18 at the earliest opportunity.²
• The second, in December, followed FDA approval for use of MCV4 in children aged 2 to 10 years. The CDC now recommends MCV4 as the preferred vaccine in this age group for those at risk (TABLE 1).³

TABLE 1
Populations at increased risk for meningococcal disease who should receive quadrivalent meningococcal conjugate vaccine

If someone at ongoing risk for meningococcal disease has been previously vaccinated with MPSV4, they should be revaccinated 3 years later with MCV4. It is not known if repeat doses of MCV4 will be needed, and if so, after what amount of time.

The MCV4 has been linked to Guillain-Barré syndrome (GBS), and a history of GBS is a precaution for its use. For those with a history of GBS who need protection against meningococcal infection, MPSV4 is an alternative.

Hepatitis A vaccine

Widespread use of inactivated hepatitis A vaccine (HAV), first licensed in 1995, has markedly reduced the incidence of hepatitis A infection (FIGURE). Recommendations for its use have been periodically revised; current recommendations include universal vaccination of all children at age 12 to 23 months, catch-up vaccination in older children in areas of high prevalence, and vaccination of those at increased risk for hepatitis A including travelers to endemic areas, users of illicit drugs and men who have sex with men.⁴

FIGURE
Reduction in incidence of hepatitis A infection

For those unvaccinated who are acutely exposed to hepatitis A virus and those traveling to areas of high prevalence who do not have time to complete the 2 doses of HAV, the only prevention available until recently has been IG. This has now changed and HAV can be used in both groups. The new recommendation for postexposure prophylaxis is that either a single dose of HAV or use of IG is acceptable.⁵ At ages 12 months to 40 years, vaccine is preferred. For those over age 40, IG is preferred but vaccine is acceptable. For children less than 12 months, the immune suppressed, and those with chronic liver disease, IG should be used.

Those traveling or working in countries with high rates of hepatitis A can be protected with either HAV or IG. A single dose of HAV is sufficient for healthy people, with a second dose at the recommended interval to complete the series. Those under age 12 months, those who choose not to receive the vaccine, and those who are allergic to the vaccine should be offered IG. Both IG and HAV should be considered for individuals who plan to travel within 2 weeks of the first HAV dose; those over age 40, the immune compromised, and those with chronic liver disease or other chronic medical conditions.

Live attenuated influenza vaccine

FluMist, the live attenuated influenza vaccine (LAIV), which is administered as an intranasal spray, is now approved for use among those 2 to 4 years of age.⁶ Previously, the LAIV was approved only for healthy, non pregnant persons, 5 to 49 years of age. The LAIV may actually be the preferred product in children as it has been shown to prevent more influenza illness than the trivalent inactivated vaccine (TIV). The LAIV should not be used in anyone with a condition listed in TABLE 2 and should not be administered to children under age 5 who have recurrent wheezing.

FluMist has also been modified in several advantageous ways:

• The dose in the sprayer is now 0.2 mL (previously 0.5 mL). One half of the dose should be administered in each nostril.
• The product no longer has to be stored frozen; it should be kept at 35° to 46°F.
• When 2 doses are needed in children under age 9 being vaccinated for the first time, the interval between doses is now 4 weeks (previously 6 weeks).

TABLE 2
LAIV (FluMist) should not be used in these groups

Children under age 9 years who receive only 1 dose of vaccine (either TIV or LAIV) the first year they are vaccinated should receive 2 doses the next year.⁶ If they fail to receive 2 doses in the next year, only a single dose is recommended after that. This is a slight modification of the previous recommendation that only 1 dose was recommended in this situation.⁷

Alternative schedule for combined hepatitis A and B vaccine

The FDA approved an alternate, 4-dose schedule for the combined hepatitis A and hepatitis B vaccine (Twinrix): at 0, 7, 21 days, and 12 months.⁸ It was previously approved only for a 3-dose schedule: at 0, 1, and 6 months. The new alternative schedule allows greater protection for travelers who need to depart in less than a month’s time.

Merck recalls some lots of Hib vaccine

On December 11, 2007, Merck announced a voluntary recall of specific lots of Haemophilus influenza type b (Hib) conjugate vaccine products: 10 lots of a monovalent Hib vaccine, PedvaxHIB, and 2 lots of a combined hepatitis B/Hib vaccine, Comvax.

Consult Merck’s Web site for the lots involved and for instructions on returning vaccine (www.merckvaccines. com/PCHRecall.pdf). The recall was prompted by concern about equipment sterility, although no vaccine has been shown to be contaminated. Children vaccinated with Merck products do not need to be revaccinated or obtain any special follow-up.

Shortage expected. It is unknown when Merck will resume production, but it is not anticipated until at least late in 2008. Other Hib-containing products are produced by Sanofi Pasteur but the supply of these products will not make up for the expected shortage.

Interim recommendations. The recall resulted in interim recommendations from the CDC.⁹ These recommendations are complicated because the dosing schedule for Hib vaccine differs by the product and the age of receipt of first vaccine when children are not on schedule. TABLE 3 lists the Hib-containing products, the recommended primary series schedule, and booster dose.

TABLE 3
Hib products

The main points are:

• Defer the booster dose at age 12 to 15 months until the shortage is resolved, except for high-risk children.
• High-risk children, who should continue to receive the booster at ages 12 to 15 months, include those with asplenia, sickle cell disease, HIV infection, and certain other immune deficiencies and cancers, and American Indian/Alaskan Native children.
• Physicians should keep track of children who have the booster deferred so they can be vaccinated when the supply improves.
• Non-recalled lots of PedvaxHIB and Comvax in the CDC stockpile will be prioritized to providers who care for predominantly American Indian/Alaskan Native children, who are at markedly in creased risk of Hib infection.
• If a child has received only 1 dose of PedvaxHIB or Comvax, their primary series can be completed with ActHIB, but 3 total doses are needed.

Children through age 59 months who are behind schedule should complete a primary series according to published recommendations.¹⁰ Physicians should call their local health department if they have any questions about what to do in a specific case.

The year 2007 was rather calm, compared to the 3 previous years in regards to new vaccines and vaccine recommendations. Although no breakthrough vaccine products came onto the market in 2007, there were new recommendations and licensure for new age groups for existing vaccines and a recall of some lots of Hib vaccines.

Meningococcal vaccine

Recommendations on the use of the quadrivalent meningococcal conjugate vaccine (MCV4) have evolved since its licensure in 2005 for use in persons 11 to 55 years of age. The first set of recommendations focused on universal vaccination of preteens, aged 11 to 12, those entering high school who had not received the vaccine previously, and others at risk for meningococcal disease including college freshmen living in dormitories.¹ The MCV4 was preferred to the older polysaccharide vaccine (MPSV4) which was recommended only for children aged 2 to 10 and adults over age 55 at increased risk.

In 2007, the CDC changed 2 of the 2005 recommendations:

• The first, in August, simplified the recommendations for teens, making MCV4 universally recommended for all those aged 11 to 18 at the earliest opportunity.²
• The second, in December, followed FDA approval for use of MCV4 in children aged 2 to 10 years. The CDC now recommends MCV4 as the preferred vaccine in this age group for those at risk (TABLE 1).³

TABLE 1
Populations at increased risk for meningococcal disease who should receive quadrivalent meningococcal conjugate vaccine

If someone at ongoing risk for meningococcal disease has been previously vaccinated with MPSV4, they should be revaccinated 3 years later with MCV4. It is not known if repeat doses of MCV4 will be needed, and if so, after what amount of time.

The MCV4 has been linked to Guillain-Barré syndrome (GBS), and a history of GBS is a precaution for its use. For those with a history of GBS who need protection against meningococcal infection, MPSV4 is an alternative.

Hepatitis A vaccine

Widespread use of inactivated hepatitis A vaccine (HAV), first licensed in 1995, has markedly reduced the incidence of hepatitis A infection (FIGURE). Recommendations for its use have been periodically revised; current recommendations include universal vaccination of all children at age 12 to 23 months, catch-up vaccination in older children in areas of high prevalence, and vaccination of those at increased risk for hepatitis A including travelers to endemic areas, users of illicit drugs and men who have sex with men.⁴

FIGURE
Reduction in incidence of hepatitis A infection

For those unvaccinated who are acutely exposed to hepatitis A virus and those traveling to areas of high prevalence who do not have time to complete the 2 doses of HAV, the only prevention available until recently has been IG. This has now changed and HAV can be used in both groups. The new recommendation for postexposure prophylaxis is that either a single dose of HAV or use of IG is acceptable.⁵ At ages 12 months to 40 years, vaccine is preferred. For those over age 40, IG is preferred but vaccine is acceptable. For children less than 12 months, the immune suppressed, and those with chronic liver disease, IG should be used.

Those traveling or working in countries with high rates of hepatitis A can be protected with either HAV or IG. A single dose of HAV is sufficient for healthy people, with a second dose at the recommended interval to complete the series. Those under age 12 months, those who choose not to receive the vaccine, and those who are allergic to the vaccine should be offered IG. Both IG and HAV should be considered for individuals who plan to travel within 2 weeks of the first HAV dose; those over age 40, the immune compromised, and those with chronic liver disease or other chronic medical conditions.

Live attenuated influenza vaccine

FluMist, the live attenuated influenza vaccine (LAIV), which is administered as an intranasal spray, is now approved for use among those 2 to 4 years of age.⁶ Previously, the LAIV was approved only for healthy, non pregnant persons, 5 to 49 years of age. The LAIV may actually be the preferred product in children as it has been shown to prevent more influenza illness than the trivalent inactivated vaccine (TIV). The LAIV should not be used in anyone with a condition listed in TABLE 2 and should not be administered to children under age 5 who have recurrent wheezing.

FluMist has also been modified in several advantageous ways:

• The dose in the sprayer is now 0.2 mL (previously 0.5 mL). One half of the dose should be administered in each nostril.
• The product no longer has to be stored frozen; it should be kept at 35° to 46°F.
• When 2 doses are needed in children under age 9 being vaccinated for the first time, the interval between doses is now 4 weeks (previously 6 weeks).

TABLE 2
LAIV (FluMist) should not be used in these groups

Children under age 9 years who receive only 1 dose of vaccine (either TIV or LAIV) the first year they are vaccinated should receive 2 doses the next year.⁶ If they fail to receive 2 doses in the next year, only a single dose is recommended after that. This is a slight modification of the previous recommendation that only 1 dose was recommended in this situation.⁷

Alternative schedule for combined hepatitis A and B vaccine

The FDA approved an alternate, 4-dose schedule for the combined hepatitis A and hepatitis B vaccine (Twinrix): at 0, 7, 21 days, and 12 months.⁸ It was previously approved only for a 3-dose schedule: at 0, 1, and 6 months. The new alternative schedule allows greater protection for travelers who need to depart in less than a month’s time.

Merck recalls some lots of Hib vaccine

On December 11, 2007, Merck announced a voluntary recall of specific lots of Haemophilus influenza type b (Hib) conjugate vaccine products: 10 lots of a monovalent Hib vaccine, PedvaxHIB, and 2 lots of a combined hepatitis B/Hib vaccine, Comvax.

Consult Merck’s Web site for the lots involved and for instructions on returning vaccine (www.merckvaccines. com/PCHRecall.pdf). The recall was prompted by concern about equipment sterility, although no vaccine has been shown to be contaminated. Children vaccinated with Merck products do not need to be revaccinated or obtain any special follow-up.

Shortage expected. It is unknown when Merck will resume production, but it is not anticipated until at least late in 2008. Other Hib-containing products are produced by Sanofi Pasteur but the supply of these products will not make up for the expected shortage.

Interim recommendations. The recall resulted in interim recommendations from the CDC.⁹ These recommendations are complicated because the dosing schedule for Hib vaccine differs by the product and the age of receipt of first vaccine when children are not on schedule. TABLE 3 lists the Hib-containing products, the recommended primary series schedule, and booster dose.

TABLE 3
Hib products

The main points are:

• Defer the booster dose at age 12 to 15 months until the shortage is resolved, except for high-risk children.
• High-risk children, who should continue to receive the booster at ages 12 to 15 months, include those with asplenia, sickle cell disease, HIV infection, and certain other immune deficiencies and cancers, and American Indian/Alaskan Native children.
• Physicians should keep track of children who have the booster deferred so they can be vaccinated when the supply improves.
• Non-recalled lots of PedvaxHIB and Comvax in the CDC stockpile will be prioritized to providers who care for predominantly American Indian/Alaskan Native children, who are at markedly in creased risk of Hib infection.
• If a child has received only 1 dose of PedvaxHIB or Comvax, their primary series can be completed with ActHIB, but 3 total doses are needed.

Children through age 59 months who are behind schedule should complete a primary series according to published recommendations.¹⁰ Physicians should call their local health department if they have any questions about what to do in a specific case.

The year 2007 was rather calm, compared to the 3 previous years in regards to new vaccines and vaccine recommendations. Although no breakthrough vaccine products came onto the market in 2007, there were new recommendations and licensure for new age groups for existing vaccines and a recall of some lots of Hib vaccines.

Meningococcal vaccine

Recommendations on the use of the quadrivalent meningococcal conjugate vaccine (MCV4) have evolved since its licensure in 2005 for use in persons 11 to 55 years of age. The first set of recommendations focused on universal vaccination of preteens, aged 11 to 12, those entering high school who had not received the vaccine previously, and others at risk for meningococcal disease including college freshmen living in dormitories.¹ The MCV4 was preferred to the older polysaccharide vaccine (MPSV4) which was recommended only for children aged 2 to 10 and adults over age 55 at increased risk.

In 2007, the CDC changed 2 of the 2005 recommendations:

• The first, in August, simplified the recommendations for teens, making MCV4 universally recommended for all those aged 11 to 18 at the earliest opportunity.²
• The second, in December, followed FDA approval for use of MCV4 in children aged 2 to 10 years. The CDC now recommends MCV4 as the preferred vaccine in this age group for those at risk (TABLE 1).³

TABLE 1
Populations at increased risk for meningococcal disease who should receive quadrivalent meningococcal conjugate vaccine

If someone at ongoing risk for meningococcal disease has been previously vaccinated with MPSV4, they should be revaccinated 3 years later with MCV4. It is not known if repeat doses of MCV4 will be needed, and if so, after what amount of time.

The MCV4 has been linked to Guillain-Barré syndrome (GBS), and a history of GBS is a precaution for its use. For those with a history of GBS who need protection against meningococcal infection, MPSV4 is an alternative.

Hepatitis A vaccine

Widespread use of inactivated hepatitis A vaccine (HAV), first licensed in 1995, has markedly reduced the incidence of hepatitis A infection (FIGURE). Recommendations for its use have been periodically revised; current recommendations include universal vaccination of all children at age 12 to 23 months, catch-up vaccination in older children in areas of high prevalence, and vaccination of those at increased risk for hepatitis A including travelers to endemic areas, users of illicit drugs and men who have sex with men.⁴

FIGURE
Reduction in incidence of hepatitis A infection

For those unvaccinated who are acutely exposed to hepatitis A virus and those traveling to areas of high prevalence who do not have time to complete the 2 doses of HAV, the only prevention available until recently has been IG. This has now changed and HAV can be used in both groups. The new recommendation for postexposure prophylaxis is that either a single dose of HAV or use of IG is acceptable.⁵ At ages 12 months to 40 years, vaccine is preferred. For those over age 40, IG is preferred but vaccine is acceptable. For children less than 12 months, the immune suppressed, and those with chronic liver disease, IG should be used.

Those traveling or working in countries with high rates of hepatitis A can be protected with either HAV or IG. A single dose of HAV is sufficient for healthy people, with a second dose at the recommended interval to complete the series. Those under age 12 months, those who choose not to receive the vaccine, and those who are allergic to the vaccine should be offered IG. Both IG and HAV should be considered for individuals who plan to travel within 2 weeks of the first HAV dose; those over age 40, the immune compromised, and those with chronic liver disease or other chronic medical conditions.

Live attenuated influenza vaccine

FluMist, the live attenuated influenza vaccine (LAIV), which is administered as an intranasal spray, is now approved for use among those 2 to 4 years of age.⁶ Previously, the LAIV was approved only for healthy, non pregnant persons, 5 to 49 years of age. The LAIV may actually be the preferred product in children as it has been shown to prevent more influenza illness than the trivalent inactivated vaccine (TIV). The LAIV should not be used in anyone with a condition listed in TABLE 2 and should not be administered to children under age 5 who have recurrent wheezing.

FluMist has also been modified in several advantageous ways:

• The dose in the sprayer is now 0.2 mL (previously 0.5 mL). One half of the dose should be administered in each nostril.
• The product no longer has to be stored frozen; it should be kept at 35° to 46°F.
• When 2 doses are needed in children under age 9 being vaccinated for the first time, the interval between doses is now 4 weeks (previously 6 weeks).

TABLE 2
LAIV (FluMist) should not be used in these groups

Children under age 9 years who receive only 1 dose of vaccine (either TIV or LAIV) the first year they are vaccinated should receive 2 doses the next year.⁶ If they fail to receive 2 doses in the next year, only a single dose is recommended after that. This is a slight modification of the previous recommendation that only 1 dose was recommended in this situation.⁷

Alternative schedule for combined hepatitis A and B vaccine

The FDA approved an alternate, 4-dose schedule for the combined hepatitis A and hepatitis B vaccine (Twinrix): at 0, 7, 21 days, and 12 months.⁸ It was previously approved only for a 3-dose schedule: at 0, 1, and 6 months. The new alternative schedule allows greater protection for travelers who need to depart in less than a month’s time.

Merck recalls some lots of Hib vaccine

On December 11, 2007, Merck announced a voluntary recall of specific lots of Haemophilus influenza type b (Hib) conjugate vaccine products: 10 lots of a monovalent Hib vaccine, PedvaxHIB, and 2 lots of a combined hepatitis B/Hib vaccine, Comvax.

Consult Merck’s Web site for the lots involved and for instructions on returning vaccine (www.merckvaccines. com/PCHRecall.pdf). The recall was prompted by concern about equipment sterility, although no vaccine has been shown to be contaminated. Children vaccinated with Merck products do not need to be revaccinated or obtain any special follow-up.

Shortage expected. It is unknown when Merck will resume production, but it is not anticipated until at least late in 2008. Other Hib-containing products are produced by Sanofi Pasteur but the supply of these products will not make up for the expected shortage.

Interim recommendations. The recall resulted in interim recommendations from the CDC.⁹ These recommendations are complicated because the dosing schedule for Hib vaccine differs by the product and the age of receipt of first vaccine when children are not on schedule. TABLE 3 lists the Hib-containing products, the recommended primary series schedule, and booster dose.

TABLE 3
Hib products

The main points are:

• Defer the booster dose at age 12 to 15 months until the shortage is resolved, except for high-risk children.
• High-risk children, who should continue to receive the booster at ages 12 to 15 months, include those with asplenia, sickle cell disease, HIV infection, and certain other immune deficiencies and cancers, and American Indian/Alaskan Native children.
• Physicians should keep track of children who have the booster deferred so they can be vaccinated when the supply improves.
• Non-recalled lots of PedvaxHIB and Comvax in the CDC stockpile will be prioritized to providers who care for predominantly American Indian/Alaskan Native children, who are at markedly in creased risk of Hib infection.
• If a child has received only 1 dose of PedvaxHIB or Comvax, their primary series can be completed with ActHIB, but 3 total doses are needed.

Children through age 59 months who are behind schedule should complete a primary series according to published recommendations.¹⁰ Physicians should call their local health department if they have any questions about what to do in a specific case.

The varicella vaccine has had tremendous success over the last few years, but its success has stalled.

The widespread use of the varicella vaccine has led to a coverage rate of 88%, and the vaccine has proven to be 85% effective. As a result, between 1995 and 2001 there was an 87% decline in hospitalizations, 66% decline in deaths, and an 87% decline in costs attributed to varicella.

However, the number of varicella cases has remained at a constant level over the past few years and sporadic outbreaks continue to occur in schools—even where high rates of immunization are achieved.^1,2

Varicella outbreaks involve both infections in unvaccinated children and “breakthrough disease” in those who have been vaccinated. If a vaccinated person is exposed to varicella, the risk of suffering a breakthrough infection is about 15%.² A 2-dose series of varicella vaccine reduces the risk by about 75%¹ (Figure).

Breakthrough disease is usually milder than infection in the unvaccinated, with fewer skin lesions, milder symptoms, and fewer complications. Those affected, though, are still infectious to others.

It was this ongoing risk of varicella that prompted the Advisory Committee on Immunization Practices (ACIP) to recommend new control measures, reported on in 2007.¹

FIGURE
2 doses of varicella vaccine reduce risk of breakthrough infection by about 75%¹

ACIP now recommends 2 doses of the vaccine

ACIP recommends the following:

• Universal administration of 2 doses of varicella vaccine; the first at ages 12 to 15 months and the second at age 4 to 6 years. (This is the same schedule as immunization against mumps, measles, and rubella.)
• Two doses of varicella vaccine, 4 to 8 weeks apart, for all adolescents and adults without evidence of immunity. (See “New criteria to prove immunity” at right.)
• A catch-up second dose for everyone who received one dose previously.
• Screening for varicella immunity in pregnant women and postpartum vaccination for those who are not immune, with 2 doses 4 to 8 weeks apart. The first dose should be administered before discharge.

Which HIV patients can get the vaccine?

ACIP has also clarified when HIV patients can be vaccinated, noting that single antigen varicella vaccine can be administered to HIV positive children if their CD4+ Tlymphocyte % is ≥15%. HIV positive adolescents and adults can be vaccinated if their CD4+ T-lymphocyte count ≥200/μL and, if 2 doses are indicated, they should be separated by at least 3 months.

2 options: Varivax and ProQuad

Two varicella vaccines contain modified live varicella virus antigen. Varivax, a single antigen vaccine, is approved for use in adults, adolescents, and children ≥12 months of age. The second vaccine, ProQuad, is approved for use in patients who are between 12 months and 12 years of age, and contains 4 viral antigens: mumps, measles, rubella, and varicella.

The quadrivalent MMRV vaccine is currently unavailable, however, and isn’t expected to be available until early 2009.³ Once the supply is stabilized, though, it will facilitate vaccination of children by decreasing the number of injections needed to achieve full immunization status.

29-year-old patient with varicellaThese 2 varicella vaccines should not be confused with the varicella zoster vaccine, Zostavax, which is approved for use in adults who are 60 years of age and older for the prevention of shingles and postherpetic neuralgia.⁴

Pregnancy precludes vaccination

Varicella vaccine is contraindicated during pregnancy and in those who have had a severe allergic reaction to any vaccine component, including gelatin; have a malignancy of the blood, bone marrow, or lymphatic system; have a congenital or hereditary immunodeficiency; or are receiving systemic immunosuppressive therapy including those on the equivalent of 2 mg/kg, or >20 mg/day, of prednisone.

You should delay giving the vaccine to patients with an acute, severe illness. There is a potential for immune globulin containing products to interfere with the effectiveness of live virus vaccines. As a result, if a patient has received blood, plasma, or immune globulin, you should wait 3 to 11 months before giving the varicella vaccine. These products should also be avoided, if possible, for 2 weeks after the vaccine has been administered.

Avoid using quadrivalent MMRV in patients with HIV infection because it contains a higher quantity of varicella antigen than the single antigen product.

One final precaution: Patients should avoid taking salicylates for 6 weeks following vaccination because of the theoretical risk of Reye’s syndrome.

The varicella vaccine has had tremendous success over the last few years, but its success has stalled.

The widespread use of the varicella vaccine has led to a coverage rate of 88%, and the vaccine has proven to be 85% effective. As a result, between 1995 and 2001 there was an 87% decline in hospitalizations, 66% decline in deaths, and an 87% decline in costs attributed to varicella.

However, the number of varicella cases has remained at a constant level over the past few years and sporadic outbreaks continue to occur in schools—even where high rates of immunization are achieved.^1,2

Varicella outbreaks involve both infections in unvaccinated children and “breakthrough disease” in those who have been vaccinated. If a vaccinated person is exposed to varicella, the risk of suffering a breakthrough infection is about 15%.² A 2-dose series of varicella vaccine reduces the risk by about 75%¹ (Figure).

Breakthrough disease is usually milder than infection in the unvaccinated, with fewer skin lesions, milder symptoms, and fewer complications. Those affected, though, are still infectious to others.

It was this ongoing risk of varicella that prompted the Advisory Committee on Immunization Practices (ACIP) to recommend new control measures, reported on in 2007.¹

FIGURE
2 doses of varicella vaccine reduce risk of breakthrough infection by about 75%¹

ACIP now recommends 2 doses of the vaccine

ACIP recommends the following:

• Universal administration of 2 doses of varicella vaccine; the first at ages 12 to 15 months and the second at age 4 to 6 years. (This is the same schedule as immunization against mumps, measles, and rubella.)
• Two doses of varicella vaccine, 4 to 8 weeks apart, for all adolescents and adults without evidence of immunity. (See “New criteria to prove immunity” at right.)
• A catch-up second dose for everyone who received one dose previously.
• Screening for varicella immunity in pregnant women and postpartum vaccination for those who are not immune, with 2 doses 4 to 8 weeks apart. The first dose should be administered before discharge.

Which HIV patients can get the vaccine?

ACIP has also clarified when HIV patients can be vaccinated, noting that single antigen varicella vaccine can be administered to HIV positive children if their CD4+ Tlymphocyte % is ≥15%. HIV positive adolescents and adults can be vaccinated if their CD4+ T-lymphocyte count ≥200/μL and, if 2 doses are indicated, they should be separated by at least 3 months.

2 options: Varivax and ProQuad

Two varicella vaccines contain modified live varicella virus antigen. Varivax, a single antigen vaccine, is approved for use in adults, adolescents, and children ≥12 months of age. The second vaccine, ProQuad, is approved for use in patients who are between 12 months and 12 years of age, and contains 4 viral antigens: mumps, measles, rubella, and varicella.

The quadrivalent MMRV vaccine is currently unavailable, however, and isn’t expected to be available until early 2009.³ Once the supply is stabilized, though, it will facilitate vaccination of children by decreasing the number of injections needed to achieve full immunization status.

29-year-old patient with varicellaThese 2 varicella vaccines should not be confused with the varicella zoster vaccine, Zostavax, which is approved for use in adults who are 60 years of age and older for the prevention of shingles and postherpetic neuralgia.⁴

Pregnancy precludes vaccination

Varicella vaccine is contraindicated during pregnancy and in those who have had a severe allergic reaction to any vaccine component, including gelatin; have a malignancy of the blood, bone marrow, or lymphatic system; have a congenital or hereditary immunodeficiency; or are receiving systemic immunosuppressive therapy including those on the equivalent of 2 mg/kg, or >20 mg/day, of prednisone.

You should delay giving the vaccine to patients with an acute, severe illness. There is a potential for immune globulin containing products to interfere with the effectiveness of live virus vaccines. As a result, if a patient has received blood, plasma, or immune globulin, you should wait 3 to 11 months before giving the varicella vaccine. These products should also be avoided, if possible, for 2 weeks after the vaccine has been administered.

Avoid using quadrivalent MMRV in patients with HIV infection because it contains a higher quantity of varicella antigen than the single antigen product.

One final precaution: Patients should avoid taking salicylates for 6 weeks following vaccination because of the theoretical risk of Reye’s syndrome.

The varicella vaccine has had tremendous success over the last few years, but its success has stalled.

The widespread use of the varicella vaccine has led to a coverage rate of 88%, and the vaccine has proven to be 85% effective. As a result, between 1995 and 2001 there was an 87% decline in hospitalizations, 66% decline in deaths, and an 87% decline in costs attributed to varicella.

However, the number of varicella cases has remained at a constant level over the past few years and sporadic outbreaks continue to occur in schools—even where high rates of immunization are achieved.^1,2

Varicella outbreaks involve both infections in unvaccinated children and “breakthrough disease” in those who have been vaccinated. If a vaccinated person is exposed to varicella, the risk of suffering a breakthrough infection is about 15%.² A 2-dose series of varicella vaccine reduces the risk by about 75%¹ (Figure).

Breakthrough disease is usually milder than infection in the unvaccinated, with fewer skin lesions, milder symptoms, and fewer complications. Those affected, though, are still infectious to others.

It was this ongoing risk of varicella that prompted the Advisory Committee on Immunization Practices (ACIP) to recommend new control measures, reported on in 2007.¹

FIGURE
2 doses of varicella vaccine reduce risk of breakthrough infection by about 75%¹

ACIP now recommends 2 doses of the vaccine

ACIP recommends the following:

• Universal administration of 2 doses of varicella vaccine; the first at ages 12 to 15 months and the second at age 4 to 6 years. (This is the same schedule as immunization against mumps, measles, and rubella.)
• Two doses of varicella vaccine, 4 to 8 weeks apart, for all adolescents and adults without evidence of immunity. (See “New criteria to prove immunity” at right.)
• A catch-up second dose for everyone who received one dose previously.
• Screening for varicella immunity in pregnant women and postpartum vaccination for those who are not immune, with 2 doses 4 to 8 weeks apart. The first dose should be administered before discharge.

Which HIV patients can get the vaccine?

ACIP has also clarified when HIV patients can be vaccinated, noting that single antigen varicella vaccine can be administered to HIV positive children if their CD4+ Tlymphocyte % is ≥15%. HIV positive adolescents and adults can be vaccinated if their CD4+ T-lymphocyte count ≥200/μL and, if 2 doses are indicated, they should be separated by at least 3 months.

2 options: Varivax and ProQuad

Two varicella vaccines contain modified live varicella virus antigen. Varivax, a single antigen vaccine, is approved for use in adults, adolescents, and children ≥12 months of age. The second vaccine, ProQuad, is approved for use in patients who are between 12 months and 12 years of age, and contains 4 viral antigens: mumps, measles, rubella, and varicella.

The quadrivalent MMRV vaccine is currently unavailable, however, and isn’t expected to be available until early 2009.³ Once the supply is stabilized, though, it will facilitate vaccination of children by decreasing the number of injections needed to achieve full immunization status.

29-year-old patient with varicellaThese 2 varicella vaccines should not be confused with the varicella zoster vaccine, Zostavax, which is approved for use in adults who are 60 years of age and older for the prevention of shingles and postherpetic neuralgia.⁴

Pregnancy precludes vaccination

Varicella vaccine is contraindicated during pregnancy and in those who have had a severe allergic reaction to any vaccine component, including gelatin; have a malignancy of the blood, bone marrow, or lymphatic system; have a congenital or hereditary immunodeficiency; or are receiving systemic immunosuppressive therapy including those on the equivalent of 2 mg/kg, or >20 mg/day, of prednisone.

You should delay giving the vaccine to patients with an acute, severe illness. There is a potential for immune globulin containing products to interfere with the effectiveness of live virus vaccines. As a result, if a patient has received blood, plasma, or immune globulin, you should wait 3 to 11 months before giving the varicella vaccine. These products should also be avoided, if possible, for 2 weeks after the vaccine has been administered.

Avoid using quadrivalent MMRV in patients with HIV infection because it contains a higher quantity of varicella antigen than the single antigen product.

One final precaution: Patients should avoid taking salicylates for 6 weeks following vaccination because of the theoretical risk of Reye’s syndrome.

Each year, the flu causes an average of about 36,000 excess deaths and over 200,000 hospitalizations in the US.^1,2 Much of this morbidity and mortality is preventable, yet each year, a large proportion of those for whom the vaccine is recommended go unvaccinated (TABLE 1).

TABLE 1
High-risk groups who went unvaccinated with influenza vaccine (2005)

Improving rates among health care workers

The recommendations of the Centers for Disease Control and Prevention (CDC) for the 2007–2008 influenza season include a new recommendation that targets health care worker vaccination rates.³ Because of the low rate of vaccination of health care workers, and the potential impact of higher coverage on both worker and patient safety, the CDC now recommends that the level of vaccination coverage be used as one measure of a facility’s patient safety quality program. The CDC also recommends the implementation of policies to encourage acceptance of the vaccine, such as requiring those caregivers who refuse immunization to sign waivers.

Improving rates among patients

To improve vaccination levels among patients, the CDC recommends:

• using reminder/recall systems
• using standing order programs
• administering the vaccine before and during the influenza season to patients during routine health care visits.

For more on improving vaccination coverage, see “Tips to help improve vaccination rates”.

Offer the vaccine to anyone who wants it

While the groups for whom vaccine is recommended are the same as last year (TABLE 2), this year the CDC is emphasizing the importance of:

• offering the vaccine to anyone who wants to reduce their risk of contracting influenza or transmitting the virus to others.
• continuing to offer vaccine to those susceptible throughout the flu season.

A minor change from last year’s recommendations involves children who are 6 months through 8 years of age who receive only 1 dose of vaccine their first year of vaccination. The CDC now recommends that these children receive 2 doses the next year. If they receive only 1 dose 2 years in a row, the CDC recommends only a single dose annually thereafter.

TABLE 2
Who should receive the influenza vaccine?

The 2 vaccines: How they differ

The same 2 vaccine types are available this year as last: trivalent influenza vaccine (TIV) and live attenuated influenza vaccine (LAIV). The vaccines include the same viral strain antigens and either can be used annually unless contraindicated (TABLE 3).

The major differences between the 2 vaccine types are:

• LAIV is administered as an intranasal spray while TIV requires an intramuscular injection
• LAIV is approved only for healthy people who are 5 to 49 years of age, whereas TIV is approved for anyone over the age of 6 months
• The interval between 2 doses in children under 9 years of age is 4 weeks for TIV and 6 to 10 weeks for LAIV
• LAIV should not be administered to family members or close contacts of those who are immunosuppressed and require a protective environment, while TIV can be used in this situation
• LAIV, being a live virus vaccine, should be administered simultaneously with, or 4 weeks after, the administration of other live virus vaccines. TIV is not a live virus vaccine, and its timing in relation to other live virus vaccines is not an issue.

TABLE 3
Contraindications and precautions for influenza vaccines

Antiviral options remain the same

Once again this year, the CDC does not recommend the use of adamantane antivirals for prophylaxis or treatment of influenza, leaving the 2 neuraminidase inhibitors, oseltamivir (Tamiflu) and zanamivir (Relenza), for these purposes. Treating flu patients with these antivirals shortens the duration of symptoms and may reduce viral shedding.

The earlier the treatment is started, the better the results. There appears to be no—or only minimal—benefit for those with uncomplicated influenza if the treatment is started more than 2 days after the onset of illness.

Consider antiviral prophylaxis for these patients

The CDC recommends that antiviral prophylaxis be considered for those who are susceptible, residing in an area with circulating influenza virus, and who:

• have not been vaccinated or were recently vaccinated (since it takes 2 weeks for immunity to develop after vaccination)
• are unvaccinated and providing care for high-risk individuals
• have a contraindication to the vaccine
• have immune deficiencies and may not respond adequately to the vaccine.

The CDC also recommends prophylaxis for all residents and staff in a long-term care facility where influenza is circulating, without regard to vaccine status. More complete information on indications, dose and duration of antivirals for prophylaxis, and treatment can be found in this year’s CDC recommendations.³

Another flu season approaches

The good news for the coming year is that the government expects that the supply of vaccine will exceed 100 million doses. This should be sufficient, unless unforeseen production problems arise.

Each year millions of doses of influenza vaccine go unused and are discarded. By following the CDC’s recommendations, and those of the Task Force on Community Preventive Services⁴ (top left), each of us can improve vaccination coverage in our area and minimize the number of hospitalizations and deaths from the flu.

Correspondence
Doug Campos-Outcalt, MD, MPA, 550 e. van buren, Phoenix, AZ 85004; [email protected].

Each year, the flu causes an average of about 36,000 excess deaths and over 200,000 hospitalizations in the US.^1,2 Much of this morbidity and mortality is preventable, yet each year, a large proportion of those for whom the vaccine is recommended go unvaccinated (TABLE 1).

TABLE 1
High-risk groups who went unvaccinated with influenza vaccine (2005)

Improving rates among health care workers

The recommendations of the Centers for Disease Control and Prevention (CDC) for the 2007–2008 influenza season include a new recommendation that targets health care worker vaccination rates.³ Because of the low rate of vaccination of health care workers, and the potential impact of higher coverage on both worker and patient safety, the CDC now recommends that the level of vaccination coverage be used as one measure of a facility’s patient safety quality program. The CDC also recommends the implementation of policies to encourage acceptance of the vaccine, such as requiring those caregivers who refuse immunization to sign waivers.

Improving rates among patients

To improve vaccination levels among patients, the CDC recommends:

• using reminder/recall systems
• using standing order programs
• administering the vaccine before and during the influenza season to patients during routine health care visits.

For more on improving vaccination coverage, see “Tips to help improve vaccination rates”.

Offer the vaccine to anyone who wants it

While the groups for whom vaccine is recommended are the same as last year (TABLE 2), this year the CDC is emphasizing the importance of:

• offering the vaccine to anyone who wants to reduce their risk of contracting influenza or transmitting the virus to others.
• continuing to offer vaccine to those susceptible throughout the flu season.

A minor change from last year’s recommendations involves children who are 6 months through 8 years of age who receive only 1 dose of vaccine their first year of vaccination. The CDC now recommends that these children receive 2 doses the next year. If they receive only 1 dose 2 years in a row, the CDC recommends only a single dose annually thereafter.

TABLE 2
Who should receive the influenza vaccine?

The 2 vaccines: How they differ

The same 2 vaccine types are available this year as last: trivalent influenza vaccine (TIV) and live attenuated influenza vaccine (LAIV). The vaccines include the same viral strain antigens and either can be used annually unless contraindicated (TABLE 3).

The major differences between the 2 vaccine types are:

• LAIV is administered as an intranasal spray while TIV requires an intramuscular injection
• LAIV is approved only for healthy people who are 5 to 49 years of age, whereas TIV is approved for anyone over the age of 6 months
• The interval between 2 doses in children under 9 years of age is 4 weeks for TIV and 6 to 10 weeks for LAIV
• LAIV should not be administered to family members or close contacts of those who are immunosuppressed and require a protective environment, while TIV can be used in this situation
• LAIV, being a live virus vaccine, should be administered simultaneously with, or 4 weeks after, the administration of other live virus vaccines. TIV is not a live virus vaccine, and its timing in relation to other live virus vaccines is not an issue.

TABLE 3
Contraindications and precautions for influenza vaccines

Antiviral options remain the same

Once again this year, the CDC does not recommend the use of adamantane antivirals for prophylaxis or treatment of influenza, leaving the 2 neuraminidase inhibitors, oseltamivir (Tamiflu) and zanamivir (Relenza), for these purposes. Treating flu patients with these antivirals shortens the duration of symptoms and may reduce viral shedding.

The earlier the treatment is started, the better the results. There appears to be no—or only minimal—benefit for those with uncomplicated influenza if the treatment is started more than 2 days after the onset of illness.

Consider antiviral prophylaxis for these patients

The CDC recommends that antiviral prophylaxis be considered for those who are susceptible, residing in an area with circulating influenza virus, and who:

• have not been vaccinated or were recently vaccinated (since it takes 2 weeks for immunity to develop after vaccination)
• are unvaccinated and providing care for high-risk individuals
• have a contraindication to the vaccine
• have immune deficiencies and may not respond adequately to the vaccine.

The CDC also recommends prophylaxis for all residents and staff in a long-term care facility where influenza is circulating, without regard to vaccine status. More complete information on indications, dose and duration of antivirals for prophylaxis, and treatment can be found in this year’s CDC recommendations.³

Another flu season approaches

The good news for the coming year is that the government expects that the supply of vaccine will exceed 100 million doses. This should be sufficient, unless unforeseen production problems arise.

Each year millions of doses of influenza vaccine go unused and are discarded. By following the CDC’s recommendations, and those of the Task Force on Community Preventive Services⁴ (top left), each of us can improve vaccination coverage in our area and minimize the number of hospitalizations and deaths from the flu.

Correspondence
Doug Campos-Outcalt, MD, MPA, 550 e. van buren, Phoenix, AZ 85004; [email protected].

Each year, the flu causes an average of about 36,000 excess deaths and over 200,000 hospitalizations in the US.^1,2 Much of this morbidity and mortality is preventable, yet each year, a large proportion of those for whom the vaccine is recommended go unvaccinated (TABLE 1).

TABLE 1
High-risk groups who went unvaccinated with influenza vaccine (2005)

Improving rates among health care workers

The recommendations of the Centers for Disease Control and Prevention (CDC) for the 2007–2008 influenza season include a new recommendation that targets health care worker vaccination rates.³ Because of the low rate of vaccination of health care workers, and the potential impact of higher coverage on both worker and patient safety, the CDC now recommends that the level of vaccination coverage be used as one measure of a facility’s patient safety quality program. The CDC also recommends the implementation of policies to encourage acceptance of the vaccine, such as requiring those caregivers who refuse immunization to sign waivers.

Improving rates among patients

To improve vaccination levels among patients, the CDC recommends:

• using reminder/recall systems
• using standing order programs
• administering the vaccine before and during the influenza season to patients during routine health care visits.

For more on improving vaccination coverage, see “Tips to help improve vaccination rates”.

Offer the vaccine to anyone who wants it

While the groups for whom vaccine is recommended are the same as last year (TABLE 2), this year the CDC is emphasizing the importance of:

• offering the vaccine to anyone who wants to reduce their risk of contracting influenza or transmitting the virus to others.
• continuing to offer vaccine to those susceptible throughout the flu season.

A minor change from last year’s recommendations involves children who are 6 months through 8 years of age who receive only 1 dose of vaccine their first year of vaccination. The CDC now recommends that these children receive 2 doses the next year. If they receive only 1 dose 2 years in a row, the CDC recommends only a single dose annually thereafter.

TABLE 2
Who should receive the influenza vaccine?

The 2 vaccines: How they differ

The same 2 vaccine types are available this year as last: trivalent influenza vaccine (TIV) and live attenuated influenza vaccine (LAIV). The vaccines include the same viral strain antigens and either can be used annually unless contraindicated (TABLE 3).

The major differences between the 2 vaccine types are:

• LAIV is administered as an intranasal spray while TIV requires an intramuscular injection
• LAIV is approved only for healthy people who are 5 to 49 years of age, whereas TIV is approved for anyone over the age of 6 months
• The interval between 2 doses in children under 9 years of age is 4 weeks for TIV and 6 to 10 weeks for LAIV
• LAIV should not be administered to family members or close contacts of those who are immunosuppressed and require a protective environment, while TIV can be used in this situation
• LAIV, being a live virus vaccine, should be administered simultaneously with, or 4 weeks after, the administration of other live virus vaccines. TIV is not a live virus vaccine, and its timing in relation to other live virus vaccines is not an issue.

TABLE 3
Contraindications and precautions for influenza vaccines

Antiviral options remain the same

Once again this year, the CDC does not recommend the use of adamantane antivirals for prophylaxis or treatment of influenza, leaving the 2 neuraminidase inhibitors, oseltamivir (Tamiflu) and zanamivir (Relenza), for these purposes. Treating flu patients with these antivirals shortens the duration of symptoms and may reduce viral shedding.

The earlier the treatment is started, the better the results. There appears to be no—or only minimal—benefit for those with uncomplicated influenza if the treatment is started more than 2 days after the onset of illness.

Consider antiviral prophylaxis for these patients

The CDC recommends that antiviral prophylaxis be considered for those who are susceptible, residing in an area with circulating influenza virus, and who:

• have not been vaccinated or were recently vaccinated (since it takes 2 weeks for immunity to develop after vaccination)
• are unvaccinated and providing care for high-risk individuals
• have a contraindication to the vaccine
• have immune deficiencies and may not respond adequately to the vaccine.

The CDC also recommends prophylaxis for all residents and staff in a long-term care facility where influenza is circulating, without regard to vaccine status. More complete information on indications, dose and duration of antivirals for prophylaxis, and treatment can be found in this year’s CDC recommendations.³

Another flu season approaches

The good news for the coming year is that the government expects that the supply of vaccine will exceed 100 million doses. This should be sufficient, unless unforeseen production problems arise.

Each year millions of doses of influenza vaccine go unused and are discarded. By following the CDC’s recommendations, and those of the Task Force on Community Preventive Services⁴ (top left), each of us can improve vaccination coverage in our area and minimize the number of hospitalizations and deaths from the flu.

Correspondence
Doug Campos-Outcalt, MD, MPA, 550 e. van buren, Phoenix, AZ 85004; [email protected].

The Centers for Disease Control and Prevention (CDC) recently released an update to its treatment guidelines for sexually transmitted diseases, stating that fluoroquinolones are no longer recommended for treatment of gonococcal infections.¹ This change resulted from a progressive increase in the rate of resistance to quinolones among gonorrhea isolated from publicly funded treatment centers across the country.

The new advisory applies to all quinolones previously recommended: ciprofloxacin, ofloxacin, and levofloxacin.

Epidemiology. Gonorrhea remains common in the United States, with nearly 340,000 cases reported in 2005. Since it is under-reported, estimates are that more than 600,000 cases occur each year.²

Neisseria gonorrhoeae causes infection of the cervix, urethra, rectum, pharynx, and adnexa. It can also cause disseminated disease that can affect joints, heart, and the meninges.

Tracking the spread of resistant cases

Since the early 1990s, fluoroquinolones have been one of the recommended treatments for gonorrhea because of their availability as effective, single-dose oral regimens. Fluoroquinolone-resistant N gonorrhea began to emerge at the end of the century and has progressed rapidly since. FIGURE 1 illustrates the proportion of fluoroquinolone-resistant N gonorrhea from the CDC’s Gonococcal Isolate Surveillance Project (GISP) by year, from 1990 to 2006.

Resistance began to emerge first among gonorrhea isolates from men who have sex with men (MSM), and resistance rates among MSM continue to be higher than in heterosexual men (FIGURE 2).

Geographic trends. In 2000, the CDC recommended that quinolones should no longer be used to treat gonorrhea in persons who contracted the infection in Asia or the Pacific. In 2002, California was added to this list. In 2004, the recommendation against quinolone use was extended to all MSM in the US.

The new recommendation against general use is based on resistance surpassing 5% of total isolates.

FIGURE 1
Percentage of N gonorrhoeae isolates with intermediate resistance or resistance to ciprofloxacin

FIGURE 2
Progressive increase of fluoroquinolone resistance

Ceftriaxone, the default treatment of choice

The loss of quinolones as a recommended gonorrhea treatment leaves only ceftriaxone, 125 mg intramuscularly (IM), as the only readily available treatment for urogenital, anorectal, and pharyngeal gonorrhea. Cefixime 400 mg as a single dose is also recommended, but is not currently available in tablet form in the US. It is available as a suspension with 100 mg per 5 cc.

Other options

Possible oral options include cefpodoxime 400 mg or cefuroxime axetil 1 g. However, neither has the official endorsement of the CDC, and neither appears effective against pharyngeal infection.

Spectinomycin 2 g intramuscularly is recommended for those with cephalosporin allergy—but, like cefixime, it is not currently available in the US, and it also is not considered effective against pharyngeal infection.

Azithromycin 2 g orally as a single dose is currently effective against gonorrhea and is an option for those with cephalosporin allergies. The CDC discourages its widespread use because of concerns about resistance.

New information regarding the availability of spectinomycin and cefixime can be obtained from local health departments or the CDC’s sexually transmitted diseases web site (www.cdc.gov/std).³

Recommended regimens for treatment of gonorrhea

Associated conditions

Treat for chlamydia if chlamydial infection is not ruled out

The CDC continues to recommend concurrent treatment for chlamydia for all persons who have gonorrhea, unless coinfection has been ruled out.

Therapies for chlamydia include azithromycin 1 g as a single dose or doxycycline 100 mg twice a day for 7 days.

Pelvic inflammatory disease and epididymitis

The treatment of both pelvic inflammatory disease (PID) and epididymitis include an option of ceftriaxone 250 mg IM plus doxycycline for either 7 days (for epididymitis) or 10 days (for PID). There are several parenteral options for PID and disseminated gonorrhea; these can be found on the CDC’s STD web site.³

Should you always retest to ensure a cure?

It is still not necessary to retest patients who have had the recommended treatments. However, patients with persistent symptoms or rapidly recurring symptoms should be retested by cultures so that drug-resistance patterns can be checked if gonorrhea is documented.

Retest for recurrence

Consider retesting all treated patients after 3 to 6 months, since anyone with a sexually transmitted infection is at risk of being reinfected.

Summary

The ongoing challenges with the evolving resistance patterns of gonorrhea illustrate the importance of physicians accurately diagnosing gonorrhea, treating with recommended regimens, reporting positive cases to the local public health department, and assisting with partner evaluation and treatment.

The Centers for Disease Control and Prevention (CDC) recently released an update to its treatment guidelines for sexually transmitted diseases, stating that fluoroquinolones are no longer recommended for treatment of gonococcal infections.¹ This change resulted from a progressive increase in the rate of resistance to quinolones among gonorrhea isolated from publicly funded treatment centers across the country.

The new advisory applies to all quinolones previously recommended: ciprofloxacin, ofloxacin, and levofloxacin.

Epidemiology. Gonorrhea remains common in the United States, with nearly 340,000 cases reported in 2005. Since it is under-reported, estimates are that more than 600,000 cases occur each year.²

Neisseria gonorrhoeae causes infection of the cervix, urethra, rectum, pharynx, and adnexa. It can also cause disseminated disease that can affect joints, heart, and the meninges.

Tracking the spread of resistant cases

Since the early 1990s, fluoroquinolones have been one of the recommended treatments for gonorrhea because of their availability as effective, single-dose oral regimens. Fluoroquinolone-resistant N gonorrhea began to emerge at the end of the century and has progressed rapidly since. FIGURE 1 illustrates the proportion of fluoroquinolone-resistant N gonorrhea from the CDC’s Gonococcal Isolate Surveillance Project (GISP) by year, from 1990 to 2006.

Resistance began to emerge first among gonorrhea isolates from men who have sex with men (MSM), and resistance rates among MSM continue to be higher than in heterosexual men (FIGURE 2).

Geographic trends. In 2000, the CDC recommended that quinolones should no longer be used to treat gonorrhea in persons who contracted the infection in Asia or the Pacific. In 2002, California was added to this list. In 2004, the recommendation against quinolone use was extended to all MSM in the US.

The new recommendation against general use is based on resistance surpassing 5% of total isolates.

FIGURE 1
Percentage of N gonorrhoeae isolates with intermediate resistance or resistance to ciprofloxacin

FIGURE 2
Progressive increase of fluoroquinolone resistance

Ceftriaxone, the default treatment of choice

The loss of quinolones as a recommended gonorrhea treatment leaves only ceftriaxone, 125 mg intramuscularly (IM), as the only readily available treatment for urogenital, anorectal, and pharyngeal gonorrhea. Cefixime 400 mg as a single dose is also recommended, but is not currently available in tablet form in the US. It is available as a suspension with 100 mg per 5 cc.

Other options

Possible oral options include cefpodoxime 400 mg or cefuroxime axetil 1 g. However, neither has the official endorsement of the CDC, and neither appears effective against pharyngeal infection.

Spectinomycin 2 g intramuscularly is recommended for those with cephalosporin allergy—but, like cefixime, it is not currently available in the US, and it also is not considered effective against pharyngeal infection.

Azithromycin 2 g orally as a single dose is currently effective against gonorrhea and is an option for those with cephalosporin allergies. The CDC discourages its widespread use because of concerns about resistance.

New information regarding the availability of spectinomycin and cefixime can be obtained from local health departments or the CDC’s sexually transmitted diseases web site (www.cdc.gov/std).³

Recommended regimens for treatment of gonorrhea

Associated conditions

Treat for chlamydia if chlamydial infection is not ruled out

The CDC continues to recommend concurrent treatment for chlamydia for all persons who have gonorrhea, unless coinfection has been ruled out.

Therapies for chlamydia include azithromycin 1 g as a single dose or doxycycline 100 mg twice a day for 7 days.

Pelvic inflammatory disease and epididymitis

The treatment of both pelvic inflammatory disease (PID) and epididymitis include an option of ceftriaxone 250 mg IM plus doxycycline for either 7 days (for epididymitis) or 10 days (for PID). There are several parenteral options for PID and disseminated gonorrhea; these can be found on the CDC’s STD web site.³

Should you always retest to ensure a cure?

It is still not necessary to retest patients who have had the recommended treatments. However, patients with persistent symptoms or rapidly recurring symptoms should be retested by cultures so that drug-resistance patterns can be checked if gonorrhea is documented.

Retest for recurrence

Consider retesting all treated patients after 3 to 6 months, since anyone with a sexually transmitted infection is at risk of being reinfected.

Summary

The ongoing challenges with the evolving resistance patterns of gonorrhea illustrate the importance of physicians accurately diagnosing gonorrhea, treating with recommended regimens, reporting positive cases to the local public health department, and assisting with partner evaluation and treatment.

The Centers for Disease Control and Prevention (CDC) recently released an update to its treatment guidelines for sexually transmitted diseases, stating that fluoroquinolones are no longer recommended for treatment of gonococcal infections.¹ This change resulted from a progressive increase in the rate of resistance to quinolones among gonorrhea isolated from publicly funded treatment centers across the country.

The new advisory applies to all quinolones previously recommended: ciprofloxacin, ofloxacin, and levofloxacin.

Epidemiology. Gonorrhea remains common in the United States, with nearly 340,000 cases reported in 2005. Since it is under-reported, estimates are that more than 600,000 cases occur each year.²

Neisseria gonorrhoeae causes infection of the cervix, urethra, rectum, pharynx, and adnexa. It can also cause disseminated disease that can affect joints, heart, and the meninges.

Tracking the spread of resistant cases

Since the early 1990s, fluoroquinolones have been one of the recommended treatments for gonorrhea because of their availability as effective, single-dose oral regimens. Fluoroquinolone-resistant N gonorrhea began to emerge at the end of the century and has progressed rapidly since. FIGURE 1 illustrates the proportion of fluoroquinolone-resistant N gonorrhea from the CDC’s Gonococcal Isolate Surveillance Project (GISP) by year, from 1990 to 2006.

Resistance began to emerge first among gonorrhea isolates from men who have sex with men (MSM), and resistance rates among MSM continue to be higher than in heterosexual men (FIGURE 2).

Geographic trends. In 2000, the CDC recommended that quinolones should no longer be used to treat gonorrhea in persons who contracted the infection in Asia or the Pacific. In 2002, California was added to this list. In 2004, the recommendation against quinolone use was extended to all MSM in the US.

The new recommendation against general use is based on resistance surpassing 5% of total isolates.

FIGURE 1
Percentage of N gonorrhoeae isolates with intermediate resistance or resistance to ciprofloxacin

FIGURE 2
Progressive increase of fluoroquinolone resistance

Ceftriaxone, the default treatment of choice

The loss of quinolones as a recommended gonorrhea treatment leaves only ceftriaxone, 125 mg intramuscularly (IM), as the only readily available treatment for urogenital, anorectal, and pharyngeal gonorrhea. Cefixime 400 mg as a single dose is also recommended, but is not currently available in tablet form in the US. It is available as a suspension with 100 mg per 5 cc.

Other options

Possible oral options include cefpodoxime 400 mg or cefuroxime axetil 1 g. However, neither has the official endorsement of the CDC, and neither appears effective against pharyngeal infection.

Spectinomycin 2 g intramuscularly is recommended for those with cephalosporin allergy—but, like cefixime, it is not currently available in the US, and it also is not considered effective against pharyngeal infection.

Azithromycin 2 g orally as a single dose is currently effective against gonorrhea and is an option for those with cephalosporin allergies. The CDC discourages its widespread use because of concerns about resistance.

New information regarding the availability of spectinomycin and cefixime can be obtained from local health departments or the CDC’s sexually transmitted diseases web site (www.cdc.gov/std).³

Recommended regimens for treatment of gonorrhea

Associated conditions

Treat for chlamydia if chlamydial infection is not ruled out

The CDC continues to recommend concurrent treatment for chlamydia for all persons who have gonorrhea, unless coinfection has been ruled out.

Therapies for chlamydia include azithromycin 1 g as a single dose or doxycycline 100 mg twice a day for 7 days.

Pelvic inflammatory disease and epididymitis

The treatment of both pelvic inflammatory disease (PID) and epididymitis include an option of ceftriaxone 250 mg IM plus doxycycline for either 7 days (for epididymitis) or 10 days (for PID). There are several parenteral options for PID and disseminated gonorrhea; these can be found on the CDC’s STD web site.³

Should you always retest to ensure a cure?

It is still not necessary to retest patients who have had the recommended treatments. However, patients with persistent symptoms or rapidly recurring symptoms should be retested by cultures so that drug-resistance patterns can be checked if gonorrhea is documented.

Retest for recurrence

Consider retesting all treated patients after 3 to 6 months, since anyone with a sexually transmitted infection is at risk of being reinfected.

Summary

The ongoing challenges with the evolving resistance patterns of gonorrhea illustrate the importance of physicians accurately diagnosing gonorrhea, treating with recommended regimens, reporting positive cases to the local public health department, and assisting with partner evaluation and treatment.