Archive for January, 2011

Updated Recommendations for Use of Meningococcal Conjugate Vaccines

MMWR Weekly  January 28, 2011 V.60 N.3  p.72-76

Advisory Committee on Immunization Practices (ACIP), 2010

On October 27, 2010, the Advisory Committee on Immunization Practices (ACIP) approved updated recommendations for the use of quadrivalent (serogroups A, C, Y, and W-135) meningococcal conjugate vaccines (Menveo, Novartis; and Menactra, Sanofi Pasteur) in adolescents and persons at high risk for meningococcal disease. These recommendations supplement the previous ACIP recommendations for meningococcal vaccination (1,2). The Meningococcal Vaccines Work Group of ACIP reviewed available data on immunogenicity in high-risk groups, bactericidal antibody persistence after immunization, current epidemiology, vaccine effectiveness (VE), and cost-effectiveness of different strategies for vaccination of adolescents. The Work Group then presented policy options for consideration by the full ACIP. This report summarizes two new recommendations approved by ACIP: 1) routine vaccination of adolescents, preferably at age 11 or 12 years, with a booster dose at age 16 years and 2) a 2-dose primary series administered 2 months apart for persons aged 2 through 54 years with persistent complement component deficiency (e.g., C5–C9, properidin, factor H, or factor D) and functional or anatomic asplenia, and for adolescents with human immunodeficiency virus (HIV) infection. CDC guidance for vaccine providers regarding these updated recommendations also is included….

Full Text

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6003a3.htm?s_cid=mm6003a3_e&s ource=govdelivery

PDF

http://www.cdc.gov/mmwr/pdf/wk/mm6003.pdf

January 31, 2011 at 1:20 am Leave a comment

Preexposure Prophylaxis for the Prevention of HIV Infection in Men Who Have Sex with Men

MMWR Weekly  January 28, 2011 V.60 N.3  p.65-68

Reports

Interim Guidance

An estimated 56,000 human immunodeficiency virus (HIV) infections occur each year in the United States (1). Men who have sex with men (MSM) account for 53% of the estimated incident infections, and surveillance data suggest that the annual number of new HIV infections among MSM has been rising since the mid-1990s (1). Strategies for reducing acquisition of HIV infection by MSM have included 1) expanded HIV testing so that infected persons can be treated and their risk for transmitting infection minimized; 2) individual, small-group, and community-level behavioral interventions to reduce risk behaviors (2); 3) promotion of condom use; 4) detection and treatment of sexually transmitted infections (3); and 5) mental health and substance abuse counseling when needed. On November 23, 2010, investigators for the Pre-Exposure Prophylaxis Initiative (iPrEX) study announced results from a multinational, randomized, double-blind, placebo-controlled, phase III clinical trial of daily oral antiretrovirals (tenofovir disoproxil fumarate [TDF] and emtricitabine [FTC]) to prevent acquisition of HIV infection among uninfected but exposed MSM (4). This report provides interim guidance to health-care providers based on the reported results of that trial, which indicated that TDF plus FTC taken orally once a day as preexposure prophylaxis (PrEP) is safe and partially effective in reducing HIV acquisition among MSM when provided with regular monitoring of HIV status and ongoing risk-reduction and PrEP medication adherence counseling….

Full Text

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6003a1.htm?s_cid=mm6003a1_e&source=govdelivery

PDF

http://www.cdc.gov/mmwr/pdf/wk/mm6003.pdf

January 29, 2011 at 1:43 pm Leave a comment

Comparative Effectiveness and Toxicity of Statins Among HIV-Infected Patients.

Clin Infect Dis. February 1, 2011 V.52  N.3 p.387-95.

Sudershan Singh1, James H. Willig2, Michael J. Mugavero2, Paul K. Crane1, Robert D. Harrington1, Robert H. Knopp1,a, Bradley W. Kosel1, Michael S. Saag2, Mari M. Kitahata1, and Heidi M. Crane1

1Department of Medicine, University of Washington, Seattle, WA

2Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama

Abstract

Background.

Dyslipidemia is common and is often treated with 3-hydroxy-3-methylglutaryl coenzyme A (HMG CoA) reductase inhibitors (statins). Little is known about the comparative effectiveness of statins among human immunodeficiency virus (HIV)-infected patients. This study compared the effectiveness and toxicity of statins among HIV-infected patients in clinical care.

Methods.

We conducted a retrospective cohort study of patients starting their initial statin medications at 2 large HIV clinics (N = 700). The primary observation was change in lipid levels during statin therapy. Secondary observations included whether individualized National Cholesterol Education Program (NCEP) goals for low density lipoprotein cholesterol (LDL-C) and non-high density lipoprotein cholesterol (non-HDL-C) levels were reached, and toxicity rates. We used linear regression to examine change in lipid levels, controlling for baseline lipid values and demographic and clinical characteristics. We conducted secondary analyses using propensity scores to address confounding by indication.

Results.

The most commonly prescribed statins were atorvastatin (N = 303), pravastatin (N = 280), and rosuvastatin (N = 95). One year after starting a statin therapy, patients who received atorvastatin or rosuvastatin had significantly greater decreases in total cholesterol, LDL-C, and non-HDL-C than patients on pravastatin. The likelihood of reaching NCEP goals for LDL-C levels was higher with the use of rosuvastatin (OR 2.1; P = .03) and atorvastatin (odds ratio [OR], 2.1; P = .001) compared with that of pravastatin. The likelihood of reaching NCEP goals for non-HDL-C levels was higher for rosuvastatin (OR 2.3; P = .045) but not atorvastatin (OR, 1.5; P = .1) compared with pravastatin. Toxicity rates were similar for all 3 statins: 7.3% for atorvastatin, 6.1% for pravastatin, and 5.3% for rosuvastatin.

Conclusions.

Our findings suggest that atorvastatin and rosuvastatin are preferable to pravastatin for treatment of HIV-infected patients with dyslipidemia, due to greater declines in total cholesterol, LDL-C, and non-HDL-C, with similar lower toxicity rates.

abstract

http://cid.oxfordjournals.org/content/52/3/387.abstract

PDF

http://cid.oxfordjournals.org/content/52/3/387.full.pdf+html

January 28, 2011 at 10:58 am Leave a comment

General Recommendations on Immunization – Recommendations of the Advisory Committee on Immunization Practices (ACIP)

MMWR Recommendations and Reports January 28, 2011  V.60 N.RR-2 p.1-60

This report is a revision of the General Recommendations on Immunization and updates the 2006 statement by the Advisory Committee on Immunization Practices (ACIP). Notable revisions to the 2006 recommendations include:

1) revisions to the tables of contraindications and precautions to vaccination, as well as a separate table of conditions that are commonly misperceived as contraindications and precautions;

2) reordering of the report content, with vaccine risk-benefit screening, managing adverse reactions, reporting of adverse events, and the vaccine injury compensation program presented immediately after the discussion of contraindications and precautions;

3) stricter criteria for selecting an appropriate storage unit for vaccines;

4) additional guidance for maintaining the cold chain in the event of unavoidable temperature deviations; and

5) updated revisions for vaccination of patients who have received a hematopoietic cell transplant. The most recent ACIP recommendations for each specific vaccine should be consulted for comprehensive details.

Full Text

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6002a1.htm?s_cid=rr6002a1_e&source=govdelivery

PDF

http://www.cdc.gov/mmwr/pdf/rr/rr6002.pdf

January 27, 2011 at 6:35 pm Leave a comment

Evidence of Person-to-Person Transmission of Oseltamivir-Resistant Pandemic Influenza A(H1N1) 2009 Virus in a Hematology Unit

J lnfect Dis. January 1, 2011  V.203 N.1  p.18-24

First confirmed person-to-person transmission of dual-resistant H1N1 in UK hospital

Catherine Moore1, Monica Galiano7, Angie Lackenby7, Tamer Abdelrahman1, Rosemary Barnes4, Meirion R. Evans3,5, Christopher Fegan2, Susannah Froude1, Mark Hastings1, Steven Knapper6, Emma Litt2, Nicola Price1, Roland Salmon3, Mark Temple3 and Eleri Davies1

1Public Health Wales Microbiology, Public Health Wales NHS Trust, Cardiff, UK

2Hematology Department, University Hospital of Wales, Heath Park

3Communicable Disease Surveillance Centre, Public Health Wales NHS Trust, Temple of Peace and Health, Cathays Park, Cardiff, UK

4Medical Microbiology, Department of Infection, Immunity and Biochemistry, Cardiff University School of Medicine, Cardiff, UK

5Department of Primary Care and Public Health, Cardiff University, Cardiff, UK

6Department of Hematology, Cardiff University, Cardiff, UK

7Respiratory Virus Unit, Virus Reference Division, Centre for Infection, Health Protection Agency, Colindale, London, United Kingdom

A recent nosocomial outbreak of oseltamivir-resistant pandemic influenza A infection has been identified in an adult hematology unit in the United Kingdom, according to findings published in the Journal of Infectious Diseases.

“Vaccination against influenza remains the best way of preventing infection in these patients, and therefore, vaccine uptake must be strongly encouraged to reduce the pool of susceptible individuals prior to the start of influenza season,” the researchers wrote.

Previous findings have established the spread of the 2009 pandemic influenza A (H1N1) strains with resistance to adamantanes. However, this is the first case to confirm person-to-person transmission of dual antiviral resistance to both adamantane and oseltamivir (Tamiflu, Roche).

Researchers collected upper respiratory tract samples from inpatients with influenza-like symptoms; positive H1N1 virus isolates were tested for the H275Y mutation.

Eleven cases were confirmed between Oct. 29 and Nov. 25, 2009. Ten were found to be associated as identified by hemagglutinin and neuraminidase genes; eight were resistant to oseltamivir; and four were from direct transmission of the resistant virus.

As a result of this outbreak, researchers suggest actively screening patients for oseltamivir-resistant H1N1 viruses, and altering treatment guidelines to include zanamivir (Relenza, GlaxoSmithKline) alone, rather than dual treatment with oseltamivir in H1N1 patients, since the H1N1 virus is still susceptible to zanamivir.

Abstract

We describe the first confirmed person-to-person transmission of oseltamivir-resistant pandemic influenza A (H1N1) 2009 virus that occurred in a hematology unit in the United Kingdom. Eleven cases of (H1N1) 2009 virus infection were identified, of which, ten were related as shown by sequence analysis of the hemagglutinin and neuraminidase genes. H275Y analysis demonstrated that 8 of 10 case patients had oseltamivir-resistant virus, with 4 of 8 case patients infected by direct transmission of resistant virus. Zanamivir should be considered as first-line therapy for influenza in patients with lymphopenic hematological conditions and uptake of influenza vaccination encouraged to further reduce the number of susceptible individuals.

Abstract

http://jid.oxfordjournals.org/content/203/1/18.abstract

PDF

http://jid.oxfordjournals.org/content/203/1/18.full.pdf+html

January 27, 2011 at 4:29 pm Leave a comment

A Systematic Review of Clinical Decision Rules for the Diagnosis of Influenza

Annals of Family Medicine 9:69-77 (2011)

Mark H. Ebell, MD, MS and Anna Afonso, BS

Department of Epidemiology and Biostatistics, College of Public Health, The University of Georgia, Athens, Georgia

CORRESPONDING AUTHOR: Mark H. Ebell, MD, MS, Department of Epidemiology and Biostatistics, College of Public Health, The University of Georgia, N122A Coverdell Building, Athens, GA 30602, ebell@uga.edu

ABSTRACT 

PURPOSE

In this study, we assessed whether multivariate models and clinical decision rules can be used to reliably diagnose influenza.

METHODS

We conducted a systematic review of MEDLINE, bibliographies of relevant studies, and previous meta-analyses. We searched the literature (1962–2010) for articles evaluating the accuracy of multivariate models, clinical decision rules, or simple heuristics for the diagnosis of influenza. Each author independently reviewed and abstracted data from each article; discrepancies were resolved by consensus discussion. Where possible, we calculated sensitivity, specificity, predictive value, likelihood ratios, and areas under the receiver operating characteristic curve.

RESULTS

A total of 12 studies met our inclusion criteria. No study prospectively validated a multivariate model or clinical decision rule, and no study performed a split-sample or bootstrap validation of such a model. Simple heuristics such as the so-called fever and cough rule and the fever, cough, and acute onset rule were each evaluated by several studies in populations of adults and children. The areas under the receiver operating characteristic curves were 0.70 and 0.79, respectively. We could not calculate a single summary estimate, however, as the diagnostic threshold varied among studies.

CONCLUSIONS

The fever and cough, and the fever, cough, and acute onset heuristics have modest accuracy, but summary estimates could not be calculated. Further research is needed to develop and prospectively validate clinical decision rules to identify patients requiring testing, empiric treatment, or neither.

Full Text

http://www.annfammed.org/cgi/content/full/9/1/69

PDF

http://www.annfammed.org/cgi/reprint/9/1/69

January 27, 2011 at 3:18 pm Leave a comment

High prevalence of echocardiographic abnormalities among HIV-infected persons in the era of highly active antiretroviral therapy.

Clin Infect Dis Feb. 2011  V.52  N.3  p.378-386

Mondy KE, Gottdiener J, Overton ET, Henry K, Bush T, Conley L, Hammer J, Carpenter CC, Kojic E, Patel P, Brooks JT; the SUN Study Investigators.

Washington University School of Medicine, St Louis, Missouri.

Abstract

Background

In the era of highly active antiretroviral therapy (HAART), human immunodeficiency virus (HIV)-infected persons have higher cardiovascular disease risk. Little is known about asymptomatic abnormalities in cardiac structure and function in this population.

Methods

The Study to Understand the Natural History of HIV/AIDS in the Era of Effective Therapy (SUN Study) is a prospective, observational, multi-site cohort of 656 HIV-infected participants who underwent baseline echocardiography during 2004-2006. We examined prevalence of and factors associated with left ventricular systolic dysfunction (LVSD), diastolic dysfunction (DD), pulmonary hypertension (PHTN), left ventricular hypertrophy (LVH), and left atrial enlargement (LAE).

Results

Participant characteristics were as follows: median age, 41 years; 24% women; 29% non-Hispanic black; 73% receiving HAART; and median CD4+ cell count, 462 cells/μL. Among evaluable participants, 18% had LVSD, 26% had DD, 57% had PHTN (right ventricular pressure >30 mm Hg), 6.5% had LVH, and 40% had LAE. In multivariate analyses, significant factors (P < .05) associated with LVSD were history of MI, elevated highly sensitive C-reactive protein (hsCRP) level, and current tobacco smoking; for DD, elevated hsCRP level and hypertension; for PHTN, current use of ritonavir; for LVH, hypertension, diabetes, non-white race, female sex with elevated body mass index, calculated as the weight in kilograms divided by the square of height in meters, of ≥25, elevated hsCRP level, and current use of abacavir; for LAE, hypertension and recent marijuana use.

Conclusions

In this large contemporary HIV cohort, the prevalence of subclinical functional and structural cardiac abnormalities was greater than expected for age. Abnormalities were mostly associated with expected and often modifiable risks. Lifestyle modification should become a greater priority in the management of chronic HIV disease.

Abstract

http://www.ncbi.nlm.nih.gov/pubmed/21217185?dopt=Abstract

January 27, 2011 at 11:58 am Leave a comment

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