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<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_3312"
                     title="Flu Vaccine a Must for All Healthcare Workers, AAP Says (CME/CE)"
                     score="0.015"
                     href="http://www.medpagetoday.com/InfectiousDisease/URItheFlu/tb/22081?impressionId=1284017348150"
                     
      &lt;p&gt;All healthcare personnel should be required to get vaccinated against influenza, according to a new policy statement from the American Academy of Pediatrics.&lt;/p&gt;
&lt;p&gt;The authors, from the AAP&apos;s Committee on Infectious Diseases, said that influenza vaccination is needed to protect patients, and that healthcare personnel have an ethical and professional obligation to be immunized.&lt;/p&gt;
&lt;p&gt;&quot;Mandatory influenza immunization for all healthcare personnel is ethically justified, necessary, and long overdue to ensure patient safety,&quot; the authors wrote online ahead of the October print issue of &lt;em&gt;Pediatrics&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;The Advisory Committee on Immunization Practices (ACIP), which provides the CDC with guidance, has been recommending influenza vaccination for healthcare personnel since the early 1980s, and earlier this year &lt;a href=&quot;http://www.medpagetoday.com/InfectiousDisease/URItheFlu/18701&quot; mce_href=&quot;http://www.medpagetoday.com/InfectiousDisease/URItheFlu/18701&quot; target=&quot;_blank&quot;&gt;recommended universal immunization&lt;/a&gt; of everybody older than 6 months.&lt;/p&gt;
&lt;p&gt;&quot;Healthcare personnel fail to lead by example if they recommend universal immunization, including influenza, to their patients but do not require it of themselves,&quot; the authors of the new AAP statement wrote. &quot;It is surprising that many healthcare personnel and the organizations that employ them have been inexcusably silent in addressing this patient safety issue.&quot;&lt;/p&gt;
&lt;p&gt;According to the Joint Commission, a vaccination rate of 80% or higher is needed to maintain the herd immunity necessary to substantially dampen the transmission of influenza in healthcare settings. The actual rate, however, has hovered around 40% in recent years.&lt;/p&gt;
&lt;p&gt;There was a slight bump last year during the H1N1 pandemic to 61.9% for trivalent seasonal vaccine, but only 37.1% of healthcare professionals received the pandemic vaccine and 34.7% received both the seasonal and pandemic vaccine.&lt;/p&gt;
&lt;p&gt;Reasons cited in the literature for refusal to receive influenza vaccine among healthcare workers include fears of developing flu-like illness or adverse effects, a perception that the risk of becoming ill with influenza is low, and concerns about exposure to thimerosal, which is found in some influenza vaccines.&lt;/p&gt;
&lt;p&gt;Voluntary programs aimed at increasing immunization rates through free and easily accessible vaccines, educational efforts, and incentives for getting vaccinated have resulted in little improvement in coverage rates, failing to overcome misconceptions about the risks and benefits of the vaccines.&lt;/p&gt;
&lt;p&gt;&quot;These findings highlight the importance of educating healthcare personnel of the risks, benefits, and basic principles of influenza vaccination,&quot; the statement authors wrote.&lt;/p&gt;
&lt;p&gt;They said mandatory vaccination seems to be the only option for achieving coverage rates greater than 80% and cited several examples of health systems that maintained rates of 88% or higher through mandatory programs.&lt;/p&gt;
&lt;p&gt;The authors pointed out that mandatory vaccination is not a new idea, since every state has laws requiring certain vaccines for school entry or attendance.&lt;/p&gt;
&lt;p&gt;Immunization requirements also have been upheld by the Supreme Court if they are a public health necessity, if the vaccines have been proven effective, if the immunization process is not onerous or unfair, and if vaccination does not put the health of the individual at risk.&lt;/p&gt;
&lt;p&gt;&quot;Despite this reality, implementation of mandatory influenza immunization programs for healthcare personnel continues to be controversial to some who argue that a mandatory program violates civil liberties,&quot; the authors wrote.&lt;/p&gt;
&lt;p&gt;The AAP has developed guidance to aid implementation of mandatory vaccination programs, which includes information on supply, payment, coding, and liability issues. It can be found at &lt;a href=&quot;http://aapredbook.aappublications.org/implementation/&quot; mce_href=&quot;http://aapredbook.aappublications.org/implementation/&quot; target=&quot;_blank&quot;&gt;www.aapredbook.org/implementation&lt;/a&gt;.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_3299"
                     title="PCV-7 Vaccine May Promote Serotype 19A Infection (CME/CE)"
                     score="0.015"
                     href="http://www.medpagetoday.com/Pediatrics/Vaccines/tb/22067?impressionId=1284017348150"
                     
      &lt;p&gt;Infants receiving a three-dose regimen of heptavalent PCV-7 pneumococcal vaccine were more likely than unvaccinated controls to pick up a nonvaccine pneumococcal strain associated with invasive infection and antibiotic resistance, researchers said.&lt;/p&gt;
&lt;p&gt;Follow-up of infants participating in a randomized trial of PCV-7 showed a relative risk of 1.75 (95% CI 1.14 to 2.70) for nasal carriage of serotype 19A among those receiving three doses of the vaccine relative to controls, according to Elisabeth A.M. Sanders, MD, PhD, of University Medical Center Utrecht in the Netherlands, and colleagues.&lt;/p&gt;
&lt;p&gt;Serotype 19A is now the leading cause of invasive and respiratory pneumococcal infection in the U.S. and is often resistant to multiple antibiotics, the researchers noted in the &lt;em&gt;Journal of the American Medical Association&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;That the heptavalent vaccine may promote infection with serotype 19A has been hypothesized but never shown convincingly, Sanders and colleagues indicated.&lt;/p&gt;
&lt;p&gt;&quot;We now have demonstrated, to our knowledge for the first time, the facilitating role of PCV-7 in nasopharyngeal acquisition of serotype 19A,&quot; they wrote.&lt;/p&gt;
&lt;p&gt;A 13-valent vaccine that includes serotype 19A coverage is now &lt;a href=&quot;http://www.medpagetoday.com/Pediatrics/Vaccines/18967&quot; mce_href=&quot;http://www.medpagetoday.com/Pediatrics/Vaccines/18967&quot; target=&quot;_blank&quot;&gt;available and recommended&lt;/a&gt; in the U.S., and Sanders and colleagues suggested that such products &quot;may [be] further aid to pneumococcal disease prevention.&quot;&lt;/p&gt;
&lt;p&gt;But they also warned that new strains would probably continue to emerge. &quot;We need to be aware that other serotypes with similar characteristics and disease potential may be the next in line to proliferate, and therefore pneumococcal surveillance remains important after introduction of expanded pneumococcal conjugate vaccines,&quot; according to Sanders and colleagues.&lt;/p&gt;
&lt;p&gt;Their analysis involved 948 infants completing a three-arm trial of PCV-7 in the Netherlands: no vaccine; doses at 2 and 4 months of age; and the same regimen with a booster dose at 11 months. The trial was conducted from 2005 to 2008, before PCV-7 was widely used in the country.&lt;/p&gt;
&lt;p&gt;Nasopharyngeal swabs were taken periodically from ages 6 to 24 months and analyzed for the presence of pneumococcal serotype 19A.&lt;/p&gt;
&lt;p&gt;Infants receiving the three-dose regimen had a cumulative rate of serotype 19A acquisition of 16.2% (95% CI 12.6% to 20.6%). In contrast, only 9.2% of the unvaccinated controls had picked up serotype 19A (95% CI 6.5% to 13.0%) during the same period.&lt;/p&gt;
&lt;p&gt;Serotype 19A acquisition associated with the two-dose schedule was 13.2% (95% CI, 9.9% to 17.4%), not significantly different from either of the other groups.&lt;/p&gt;
&lt;p&gt;The use of antibiotics in the previous six months did not affect rates of serotype 19A acquisition, Sanders and colleagues reported.&lt;/p&gt;
&lt;p&gt;A total of 28 different sequence types were identified in the samples, including six not previously seen before. Five of these showed intermediate susceptibility to penicillin; three others were resistant to erythromycin and azithromycin. None of these eight isolates were seen in unvaccinated controls.&lt;/p&gt;
&lt;p&gt;Sanders and colleagues indicated that some of the serotypes they found were consistent with a hypothesis that vaccination promotes a process called capsular switching, in which clones of one serotype change the polysaccharides in their coats to become another serotype.&lt;/p&gt;
&lt;p&gt;Variations in the genomic sequences for some serotypes &quot;could have been the result of capsular switching under vaccine pressure,&quot; the researchers wrote.&lt;/p&gt;
&lt;p&gt;They noted that their study was a post-hoc analysis of trial data and no correction was made for multiple testing, both limitations to the study. Also, they noted that nasopharyngeal colonization does not predictably lead to actual disease.&lt;/p&gt;
&lt;p&gt;Another major limitation was that the study did not include a four-dose vaccine schedule that is the norm for pneumococcal immunization.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The analysis was funded by the Dutch Ministry of Health.&lt;/p&gt;&lt;p&gt;Authors of the study reported consulting relationships with GlaxoSmithKline and Wyeth/Pfizer, and research funding from those companies and Novartis and Baxter.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_3275"
                     title="Kids on HAART Would Benefit from Revaccinations (CME/CE)"
                     score="0.014"
                     href="http://www.medpagetoday.com/clinical-context/HIVAIDS/tb/22037?impressionId=1284017348150"
                     
      &lt;p&gt;Children with HIV who received standard childhood immunizations before starting on highly active antiretroviral therapy (HAART) could benefit from revaccination, a review published in the September issue of &lt;em&gt;Lancet Infectious Diseases&lt;/em&gt; suggests.&lt;/p&gt;
&lt;p&gt;The proportion of those with an immune response after HAART began was highly variable, with no clear trend by type of vaccine, according to a meta-analysis of 38 studies conducted by Catherine G. Sutcliffe, PhD, and William J. Moss, MD, of Johns Hopkins University.&lt;/p&gt;
&lt;p&gt;For instance, they found for tetanus the proportion with an immune response ranged from 38% to 77%. Proportions ranged from 40% to 65% for diphtheria, 1% to 100% for hepatitis B virus (HBV), and 25% to 87% by serotype for pneumococcal vaccines.&lt;/p&gt;
&lt;p&gt;The proportion of children with an immune response to the measles, mumps, rubella vaccine (MMR) after starting HAART ranged from 42% to 45% for measles virus and 27% to 66% for rubella virus.&lt;/p&gt;
&lt;p&gt;Studies looking at revaccinations after HAART was started found that within the first three months, the proportion of children with an immune response was 53% to 100% for tetanus toxoid, 75% for conjugate Hib vaccine, 46% to 92% for HBV vaccine, 29% to 96% by serotype for pneumococcal vaccine, and 50% to 100% by strain for influenza vaccine. &lt;ul&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;For the meta-analysis, Sutcliffe and Moss looked at studies addressing several different questions about HAART and vaccines. For the question of whether children taking HAART have protective immunity to vaccine-preventable diseases, studies were included if children were vaccinated before being started on HAART and measures of immunity were reported after the start of HAART but before revaccination.&lt;/p&gt;
&lt;p&gt;For questions about the short-term (three months or less) and the long-term (more than three months) immune response to vaccination while on HAART, studies were included if children were revaccinated or received new vaccines to which they had no prior exposure after being started on HAART and either short-term or long-term immune responses were measured.&lt;/p&gt;
&lt;p&gt;Two studies looked at by the authors reported antibody concentrations before and after HAART. In one of those, a Kenyan study of the measles vaccine, researchers found that the proportion of children who were seropositive increased from 33% before HAART to 42% after HAART.&lt;/p&gt;
&lt;p&gt;However, 53% of the children who were seropositive before HAART lost protective immunity, whereas 40% of children who were seronegative or had borderline antibody concentrations became seropositive after receiving HAART for six months.&lt;/p&gt;
&lt;p&gt;In terms of the strength of immunizations, in general the studies found that immunity declined but a high proportion of children maintained immunity about a year after vaccination.&lt;/p&gt;
&lt;p&gt;For tetanus toxoid, one U.S. study reported a decline from 74% seropositive at four weeks to 38% by 32 weeks after vaccination, although in three other studies 85% to 90% of children maintained immunity one year after vaccination.&lt;/p&gt;
&lt;p&gt;For pertussis, antibody concentration declined from 22.3 EU/mL at eight weeks to 10.1 EU/mL by 48 weeks and 6.8 EU/mL by 96 weeks after vaccination.&lt;/p&gt;
&lt;p&gt;For HBV, the proportion of seropositive children decreased from 46% eight weeks after revaccination to 38% after 96 weeks and 25% after a median of 4.6 years.&lt;/p&gt;
&lt;p&gt;All children remaining in the HBV study after a median of 4.6 years were revaccinated a second time. Of the children who were seronegative within one week of the second revaccination, 37% seroconverted four weeks after vaccination.&lt;/p&gt;
&lt;p&gt;The authors wrote that although HAART is effective in reducing morbidity and mortality in HIV-infected children by suppressing viral replication and restoring immune function, &quot;immune reconstitution in children is primarily through the generation of naive T cells rather than expansion of memory T cells, as in adults.&quot;&lt;/p&gt;
&lt;p&gt;Therefore, they wrote, &quot;HAART is unlikely to restore memory T cells for vaccine antigens to which children were exposed before treatment, but should restore the ability of the immune system to respond to new antigens.&quot;&lt;/p&gt;
&lt;p&gt;Because levels of immunity to vaccine-preventable diseases in HIV-infected children were generally low, the majority of children on HAART would benefit from revaccination, although the best timing of vaccination after starting HAART is still not known, either for revaccination or for primary vaccination with new vaccines, according to the researchers.&lt;/p&gt;
&lt;p&gt;&quot;Waning immunity after revaccination and vaccination with new vaccines was greater and more rapid than in children not infected with HIV, who typically maintain high antibody concentrations years after vaccination,&quot; they added.&lt;/p&gt;
&lt;p&gt;The authors cited several limitations to their meta-analysis, including the fact that few studies were identified for each vaccine and there was great heterogeneity in study design, eligibility criteria, characteristics of study populations, definitions of immunity, and presence of a comparison group. In addition, vaccine-induced immunity could not be distinguished from immunity derived from natural infection.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The authors declared that they had no conflicts of interest. No funding information for the study was given.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_3274"
                     title="New Guidelines Out for Pneumococcal Vaccine (CME/CE)"
                     score="0.014"
                     href="http://www.medpagetoday.com/InfectiousDisease/Vaccines/tb/22034?impressionId=1284017348150"
                     
      &lt;p&gt;Adults with asthma and those who smoke should receive the 23-valent polysaccharide vaccine to prevent pneumococcal disease, according to new recommendations from the CDC.&lt;/p&gt;
&lt;p&gt;But the agency&apos;s Advisory Committee on Immunization Practices (ACIP) is no longer recommending routine use of the vaccine for all Alaska Natives and American Indians younger than 65 unless they have medical or behavioral reasons  --  such as alcohol and tobacco use  --  that put them at increased risk, or if they live in areas where the rates of invasive disease are high.&lt;/p&gt;
&lt;p&gt;The new recommendations were published in the Sept. 3 issue of &lt;em&gt;Morbidity and Mortality Weekly Report&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Herd effects have reduced the overall incidence of pneumococcal infections since the introduction of the 7-valent vaccine in 2000, but invasive disease  --  bacteremia, meningitis, or infection at other normally sterile sites  --  remains a threat, with 43,500 cases and 5,000 deaths occurring in 2009, according to the CDC.&lt;/p&gt;
&lt;p&gt;Between 1998 and 2007, the incidence of invasive disease among adults younger than 65 with high-risk conditions increased from 52% to 59%, and from 69% to 81% in those 65 and older.&lt;/p&gt;
&lt;p&gt;&quot;This trend suggests that adults with high-risk conditions might not have benefited as much from the indirect protective effects of childhood [7-valent pneumococcal conjugate vaccine] immunization as persons who are relatively healthy,&quot; the CDC report stated.&lt;/p&gt;
&lt;p&gt;As support for the asthma recommendation, CDC cited a case-control study in Tennessee that found an adjusted odds ratio of 2.4 (95% CI 1.8 to 3.3) for invasive pneumococcal disease in patients with asthma compared with those without the disease.&lt;/p&gt;
&lt;p&gt;And for smoking, CDC data from 2001 to 2003 suggested that more than half of patients ages 18 to 64 with invasive disease were current cigarette smokers.&lt;/p&gt;
&lt;p&gt;In addition, a case-control study identified a fourfold increased risk for smokers (adjusted OR 4.1, 95% CI 2.4 to 7.3), with risk correlating with number of cigarettes smoked and pack-years of smoking.&lt;/p&gt;
&lt;p&gt;Along with the vaccine, smokers should be given smoking cessation guidance, because the risk for invasive disease decreases by almost 15% each year after quitting.&lt;/p&gt;
&lt;p&gt;Estimated efficacy of the 23-valent vaccine, according to observational studies, ranges from 50% to 80% among immuncompetent adults, but efficacy is less clear, ranging from 10% to 74%, among the immunocompromised and the elderly.&lt;/p&gt;
&lt;p&gt;The report also states that everyone should receive the pneumococcal vaccine at age 65.&lt;/p&gt;
&lt;p&gt;Anyone who received a dose of the vaccine before 65 can be given a second dose if five years have passed since the first dose, and immunocompromised or asplenic patients ages 19 to 64 should be given a second dose five years after the first.&lt;/p&gt;
&lt;p&gt;Multiple revaccinations are not recommended because of uncertainty about benefits and risks.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The authors are employees of the CDC.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_3300"
                     title="Adult Smoking Hits Plateau"
                     score="0.013"
                     href="http://www.medpagetoday.com/PrimaryCare/Smoking/tb/22068?impressionId=1284017348150"
                     
      &lt;p&gt;One in five U.S. adults continues to smoke cigarettes  --  a percentage that hasn&apos;t budged since 2005  --  suggesting that more aggressive efforts are needed to reduce smoking-related diseases and deaths, the CDC said.&lt;/p&gt;
&lt;p&gt;Data from the 2009 National Health Interview Survey and the Behavioral Risk Factor Surveillance System (BRFSS) indicated that 20.6% of Americans 18 and older reported being current smokers, according to an early-release report in the CDC&apos;s &lt;em&gt;Morbidity and Mortality Weekly Report&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;In 2005, smoking prevalence stood at 20.9%  --  not significantly different from the 2009 figure or the rate for any year in between, according to the &lt;em&gt;MMWR&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;&quot;There has been no progress in reducing that number in five years,&quot; said Thomas Frieden, MD, director of CDC, in a conference call with reporters.&lt;/p&gt;
&lt;p&gt;Frieden said shrewd marketing by tobacco companies and stagnation in anti-smoking efforts have combined to stall a 40-year decline in smoking prevalence that began in 1964.&lt;/p&gt;
&lt;p&gt;He said full implementation of his agency&apos;s recommendations for state-level programs to reduce smoking would help resume progress toward elimination of smoking, but these have been underfunded  --  not necessarily because of the recession.&lt;/p&gt;
&lt;p&gt;&quot;Comprehensive evidence-based state programs are not being widely implemented,&quot; Frieden complained. &quot;Last year, states took in about $25 billion from tobacco taxes and the master settlement agreement [related to tobacco litigation], but spent only $700 million, about three cents of every dollar,&quot; on anti-smoking programs.&lt;/p&gt;
&lt;p&gt;He said spending 15 cents of each dollar in tobacco-related revenue could reduce the number of people who smoke by 5 million  --  shaving more than two percentage points off the national prevalence figure.&lt;/p&gt;
&lt;p&gt;Also, a separate &lt;em&gt;MMWR&lt;/em&gt; report based on National Health and Nutrition Examination Survey (NHANES) data found that some 88 million nonsmokers are exposed to secondhand smoke, as evidenced by serum levels of the nicotine metabolite cotinine.&lt;/p&gt;
&lt;p&gt;The prevalence of secondhand smoke exposure  --  at around four in 10 nonsmokers  --  has declined from 1999 to 2008, the study indicated, but it too appears to have hit a plateau.&lt;/p&gt;
&lt;p&gt;The NHANES data from 2007 to 2008 showed cotinine (at least 0.05 ng/mL) in 40.1% of nonsmokers, not significantly different from the 39.1% seen in the previous biennium or the 41.7% found in 2001 to 2002. In 1999 to 2000 the prevalence of cotinine in nonsmokers was 52.5%.&lt;/p&gt;
&lt;p&gt;Both studies also found that certain populations are more likely to inhale tobacco smoke  --  either by choice or through secondhand exposure.&lt;/p&gt;
&lt;p&gt;Current smokers  --  defined as those who reported having smoked at least 100 cigarettes in their lifetimes and were smoking regularly at the time they were interviewed  --  are more likely to be male, poor, non-Hispanic white or black, lacking a high school diploma, and living in the South or Midwest, the CDC reported.&lt;/p&gt;
&lt;p&gt;Secondhand smoke exposure was greatest in children and teens, males, and non-Hispanic blacks.&lt;/p&gt;
&lt;p&gt;Hispanic and Asian women, people with higher levels of education, and older adults continued to meet the Healthy People 2010 target of &amp;#8804;12% prevalence of smoking.&lt;/p&gt;
&lt;p&gt;While the CDC noted that smoking prevalence was lowest among Asian and Hispanic women, the current findings could not assess specific Asian and Hispanic subgroups.&lt;/p&gt;
&lt;p&gt;Frieden lambasted tobacco companies for &quot;sidestepping&quot; policies aimed at discouraging tobacco use, especially among young people.&lt;/p&gt;
&lt;p&gt;&quot;They insure that every cigarette they sell delivers nicotine quickly and efficiently to keep people addicted,&quot; he thundered. &quot;The industry uses targeted price discounts ... to get kids to start smoking,&quot; said Frieden.&lt;/p&gt;
&lt;p&gt;He also accused companies of targeting the youth market with flavored nicotine-laced lozenges &quot;to get around the ban on flavored cigarettes,&quot; as well as employing &quot;subtle and not-so-subtle ways&quot; to suggest some tobacco products are less harmful than others.&lt;/p&gt;

    </recommendedItem>
</recommendedContent>