Archive for February, 2010

Cost-Effectiveness of Vaccination against Invasive Pneumococcal Disease among People 50 through 64 Years of Age: Role of Comorbid Conditions and Race

Annals of Internal Medicine  June 2003 V.138  N.12  p.960-968

Jane E. Sisk, PhD; William Whang, MD, MS; Jay C. Butler, MD; Vishnu-Priya Sneller, MBBS, PhD; and Cynthia G. Whitney, MD, MPH

From the Mount Sinai School of Medicine and Mailman School of Public Health, Columbia University, New York, New York; Massachusetts General Hospital, Boston, Massachusetts; and Centers for Disease Control and Prevention, Anchorage, Alaska, and Atlanta, Georgia.


Guidelines are increasingly recommending preventive services starting at 50 years of age, and policymakers are considering such a recommendation for pneumococcal polysaccharide vaccination. The finding that pneumococcal vaccination is cost-saving for people 65 years of age or older raises the question of the vaccination’s implications for other older adults, especially black people, whose disease incidence exceeds that of nonblack people, and those with high-risk conditions.


To assess the implications of vaccinating black and nonblack people 50 through 64 years of age against invasive pneumococcal disease.


Cost-effectiveness analysis.

Data Sources

Published literature for vaccination effectiveness and cost estimates; data on disease incidence and case-fatality rates from the Centers for Disease Control and Prevention.

Target Population

Hypothetical cohort 50 through 64 years of age with the 1995 U.S. age distribution.

Time Horizon





Pneumococcal polysaccharide vaccination compared with no vaccination.

Outcome Measures

Incremental medical costs and health effects, in quality-adjusted life-years per vaccinee.

Results of Base-Case Analysis

Vaccination saved medical costs and improved health among high-risk black people ($27.55 savings per vaccinee) and nonblack people ($5.92 savings per vaccinee), excluding survivors’ future costs. For low-risk black and nonblack people and the overall general population, vaccination cost $2477, $8195, and $3434, respectively, to gain 1 year of healthy life.

Results of Sensitivity Analysis

Excluding survivors’ future costs, in the general immunocompetent population, cost per quality-adjusted life-year in global worst-case results ranged from $21 513 for black people to $68 871 for nonblack people; in the high-risk population, cost ranged from $11 548 for black people to $39 000 for nonblack people. In the global best case, vaccination was cost-saving for black and nonblack people in the general immunocompetent and high-risk populations, excluding survivors’ future costs. The cost-effectiveness range was narrower in probabilistic sensitivity analyses, with 95% probabilistic intervals ranging from cost-saving to $1594 for black people and from cost-saving to $12 273 for nonblack people in the general immunocompetent population. Costs per quality-adjusted life-year for low-risk people with case-fatality rates from 1998 were $2477 for black people and $8195 for nonblack people, excluding survivors’ medical costs.


These results support the current recommendation to vaccinate high-risk people and provide useful information for considering extending the recommendation to the general population 50 through 64 years of age. Lack of evidence about the effectiveness of revaccination for people 65 years of age or older, when disease risks are higher, argues for further research to guide vaccination policy.



February 27, 2010 at 4:25 pm Leave a comment

Outbreak of 2009 Pandemic Influenza A (H1N1) on a Peruvian Navy Ship — June–July 2009

MMWR Weekly  February 19, 2010  V.59  N.6 p.162-165

On June 25, 2009, a naval cadet reported to the infirmary of a 355-crewman Peruvian Navy ship with a febrile acute respiratory infection (FARI) 5 days after the ship docked in San Francisco, California. Pandemic 2009 influenza A (H1N1) virus was suspected as the cause because it was circulating in the city at that time. A test for pandemic H1N1 by real-time reverse transcription–polymerase chain reaction (rRT-PCR) was positive. During the subsequent 3 weeks, as the ship continued its cruise, 77 additional crew members developed confirmed pandemic H1N1 influenza. The U.S. Naval Medical Research Center Detachment (NMRCD), in collaboration with the Peruvian Navy, conducted an investigation to describe the outbreak and determine the attack rate for pandemic H1N1 influenza on the ship. This report summarizes the results of that investigation, which indicated that, of the 85 patients with FARI, 78 (92%) tested positive for pandemic H1N1 by rRT-PCR. The attack rate for confirmed pandemic H1N1 influenza was 22.0%. The most frequent symptoms …

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February 27, 2010 at 3:25 pm Leave a comment

Guillain-Barré Syndrome Among Recipients of Menactra® Meningococcal Conjugate Vaccine — United States, June–July 2005

MMWR  October 14, 2005   V.54  N.40  P. 1023-1025

On October 6, this report was posted as an MMWR Dispatch on the MMWR website (

On January 14, 2005, a quadrivalent (A, C, Y, and W135) meningococcal conjugate vaccine (Meningococcal Polysaccharide Diphtheria Toxoid Conjugate Vaccine, Menactra®, Sanofi-Pasteur, Swiftwater, Pennsylvania) (MCV4) was licensed in the United States. MCV4 is a tetravalent vaccine; each 0.5-mL dose contains 4 µg each of capsular polysaccharide from Neisseria meningitidis serogroups A, C, Y, and W-135 conjugated to 48 µg of diphtheria toxoid. In February 2005, the Advisory Committee on Immunization Practices (ACIP) recommended routine vaccination of adolescents at the preadolescent health-care visit (at ages 11–12 years) (1). For persons who have not been vaccinated previously, ACIP recommended vaccination before …

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February 27, 2010 at 3:16 pm Leave a comment

Preventing Pneumococcal Disease Among Infants and Young Children

MMWR October 6, 2000   V.49  N.RR 9   P. 1 – 38

Recommendations of the Advisory Committee on Immunization Practices (ACIP)

Advisory Committee on Immunization Practices

Membership List, June 2000

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February 27, 2010 at 3:10 pm Leave a comment

Updated Recommendation from the Advisory Committee on Immunization Practices (ACIP) for Revaccination of Persons at Prolonged Increased Risk for Meningococcal Disease

MMWR  September 25, 2009  V.58  N.37  p.1042-1043

The Advisory Committee on Immunization Practices (ACIP) recommends quadrivalent meningococcal conjugate vaccine, (MCV4) (Menactra, Sanofi Pasteur, Swiftwater, Pennsylvania) for all persons aged 11–18 years and for persons aged 2–55 years at increased risk for meningococcal disease (1–3). MCV4 is licensed as a single dose. Because of the high risk for meningococcal disease among certain groups and limited data on duration of protection, at its June 2009 meeting ACIP recommended that persons previously vaccinated with either MCV4 or MPSV4 (Menomune, Sanofi Pasteur) who are at prolonged increased risk for meningococcal disease should be revaccinated with MCV4. Persons who previously were vaccinated at age ≥7 years and are at prolonged increased risk should be revaccinated 5 years after their previous meningococcal vaccine, and persons who previously were vaccinated at ages 2–6 years and are at prolonged increased risk should be revaccinated 3 years after their previous meningococcal vaccine. Persons at prolonged increased risk for …

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February 27, 2010 at 3:05 pm Leave a comment

Intravenous and Inhalational Colistin–Induced Respiratory Failure

Clinical Infectious Diseases  15 March 2010  V.50  N.6  e38–e40


Krista Wahby,1 Teena Chopra,2 and Pranatharthi Chandrasekar2

1Pharmacy Department, Harper University Hospital/Hutzel Women’s Hospital, Detroit Medical Center, Wayne State University, and 2Division of Infectious Diseases, Harper University Hospital, Wayne State University/Karmanos Cancer Institute Detroit, Michigan

The emergence of highly resistant gram-negative pathogens in hospitals around the world has placed emphasis on colistin, a seemingly ancient drug. Respiratory failure from colistin was reported in the years following its release; however, there are no recent reports of colistin-induced respiratory failure. We report a case of intravenous colistin– and, later, inhalational colistin–induced respiratory failure.



February 26, 2010 at 6:21 pm Leave a comment

Fulminant Infectious Mononucleosis and Recurrent Epstein-Barr Virus Reactivation in an Adolescent

Clinical Infectious Diseases  15 March 2010  V.50  N.6  e34–e37

Jamie P. Nourse,1 Kimberley Jones,1 Ujjwal Dua,1 Naomi Runnegar,3 David Looke,3 Chris Schmidt,2

Siok-Keen Tey,5 Glen Kennedy,5,a and Maher K. Gandhi1,4,a

1Clinical Immunohaematology Laboratory and 2Cancer Immunotherapy Laboratory, Queensland Institute of Medical Research, Departments of 3Infectious Diseases and 4Haematology, Princess Alexandra Hospital, and 5Department of Haematology, Royal Brisbane Hospital, Brisbane, Australia

We describe a unique case of fulminant infectious mononucleosis and recurrent Epstein-Barr virus reactivation presenting in an adolescent. Detailed assays of Epstein-Barr virus–specific T cell immunity revealed defects in the patient’s T cell receptor signalling pathway characterized by a lack of interleukin-2 and CD25 expression, which may have contributed to her clinical course. Allogeneic stem cell transplantation reversed the clinical and laboratory phenotype.



February 26, 2010 at 6:19 pm Leave a comment

Protective Effects of the 23-Valent Pneumococcal Polysaccharide Vaccine in the Elderly Population: The EVAN-65 Study

Clin Inf Diseases  1 Oct 2006  V.43 N.7  p.860–868

Angel Vila-Córcoles,1 Olga Ochoa-Gondar,1 Imma Hospital,1 Xabier Ansa,1 Angels Vilanova,2 Teresa Rodríguez,3 Carl Llor,1 and the EVAN Study Groupa

1Primary Care Service of Tarragona-Valls, Catalonian Health Institute, and 2Department of Laboratory and Microbiology, Joan XXIII Hospital, Tarragona, and 3Department of Statistic and Research of IDIAP Jordi Gol i Gurina, Barcelona, Spain


The 23-valent polysaccharide pneumococcal vaccine (PPV) is currently recommended for elderly persons and persons who are at high risk of infection. However, the effectiveness of the 23-valent PPV remains controversial. We assessed the effectiveness of this vaccine in older adults.


A prospective cohort study was conducted from January 2002 through April 2005; it included all community-dwelling individuals aged 65 years who were assigned to 1 of 8 primary health care centers in Tarragona, Spain (11,241 subjects). The primary outcomes were invasive pneumococcal disease, pneumococcal pneumonia, overall pneumonia rate, and death due to pneumonia. All cases were validated by a check of the clinical records. The association between pneumococcal vaccination and the risk of each outcome was evaluated by means of multivariate Cox proportional hazard models, adjusted for age, sex, comorbidity, immunocompetence, and influenza vaccine status.


Pneumococcal vaccination was associated with significant reductions in the risk of hospitalization for pneumonia (hazard ratio [HR], 0.74; 95% confidence interval [CI], 0.59–0.92) and in the overall pneumonia rate (HR, 0.79; 95% CI, 0.64–0.98). The incidence of invasive pneumococcal disease was low (64 cases per 100,000 person‐years), and a considerable protective effect against invasive pneumococcal disease did not attain statistical significance (HR, 0.60; 95% CI, 0.22–1.65). However, the vaccine showed a significant effectiveness of 45% to prevent pneumococcal pneumonia (HR, 0.55; 95% CI, 0.34–0.88). Finally, vaccination was associated with a significant 59% reduction in the risk of death due to pneumonia among vaccinated subjects (HR, 0.41; 95% CI, 0.23–0.72)


These results indicate that the 23-valent PPV effectively prevented pneumococcal pneumonia (with or without bacteremia) and decreased the rates of overall pneumonia and of mortality due to pneumonia in older adults, providing new arguments for systematic vaccination in the elderly population.



February 26, 2010 at 6:18 pm Leave a comment

Abdominal-Wall Abscess

N Engl J of Medicine 25 Feb 2010 V.362 N.8  e.24

Images in Clinical Medicine



February 25, 2010 at 10:46 am Leave a comment

An Algorithm for Tuberculosis Screening and Diagnosis in People with HIV

N Engl J of Medicine 25 Feb 2010 V.362 N.8  p.707-716

Kevin P. Cain, M.D., Kimberly D. McCarthy, M.M., Charles M. Heilig, Ph.D., Patama Monkongdee, M.Sc., Theerawit Tasaneeyapan, M.Sc., Nong Kanara, M.D., Michael E. Kimerling, M.D., M.P.H., Phalkun Chheng, M.D., M.P.H., Sopheak Thai, M.D., Borann Sar, M.D., Ph.D., Praphan Phanuphak, M.D., Ph.D., Nipat Teeratakulpisarn, M.D., Nittaya Phanuphak, M.D., Nguyen Huy Dung, M.D., Hoang Thi Quy, M.D., Le Hung Thai, M.D., and Jay K. Varma, M.D.


Tuberculosis screening is recommended for people with human immunodeficiency virus (HIV) infection to facilitate early diagnosis and safe initiation of antiretroviral therapy and isoniazid preventive therapy. No internationally accepted, evidence-based guideline addresses the optimal means of conducting such screening, although screening for chronic cough is common.


We consecutively enrolled people with HIV infection from eight outpatient clinics in Cambodia, Thailand, and Vietnam. For each patient, three samples of sputum and one each of urine, stool, blood, and lymph-node aspirate (for patients with lymphadenopathy) were obtained for mycobacterial culture. We compared the characteristics of patients who received a diagnosis of tuberculosis (on the basis of having one or more specimens that were culture-positive) with those of patients who did not have tuberculosis to derive an algorithm for screening and diagnosis.


Tuberculosis was diagnosed in 267 (15%) of 1748 patients (median CD4+ T-lymphocyte count, 242 per cubic millimeter; interquartile range, 82 to 396). The presence of a cough for 2 or 3 weeks or more during the preceding 4 weeks had a sensitivity of 22 to 33% for detecting tuberculosis. The presence of cough of any duration, fever of any duration, or night sweats lasting 3 or more weeks in the preceding 4 weeks was 93% sensitive and 36% specific for tuberculosis. In the 1199 patients with any of these symptoms, a combination of two negative sputum smears, a normal chest radiograph, and a CD4+ cell count of 350 or more per cubic millimeter helped to rule out a diagnosis of tuberculosis, whereas a positive diagnosis could be made only for the 113 patients (9%) with one or more positive sputum smears; mycobacterial culture was required for most other patients.


In persons with HIV infection, screening for tuberculosis should include asking questions about a combination of symptoms rather than only about chronic cough. It is likely that antiretroviral therapy and isoniazid preventive therapy can be started safely in people whose screening for all three symptoms is negative, whereas diagnosis in most others will require mycobacterial culture.



February 25, 2010 at 10:44 am Leave a comment

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