Bruce Dixon

Camera-in-a-capsule technology may be as effective as the more invasive conventional upper endoscopy at detecting esophageal varices, according to tandem studies.

In a pilot trial, American, Israeli, and French investigators compared conventional esophagogastroduodenoscopy (EGD) with the commercially available PillCam ESO.

The targets were esophageal varices, which affect a large majority of patients with cirrhosis and portal hypertension, according to Dr. Glenn M. Eisen and colleagues at Oregon Health and Science University, Portland (Endoscopy 2006;38:31–5).

The study involved 32 patients with cirrhosis who were undergoing clinically indicated EGD for screening or surveillance for esophageal varices. All underwent a PillCam ESO study followed by an EGD within 48 hours. Capsule videos were assessed by an investigator who was blinded to the patients' medical histories and EGD findings. The median esophageal transit time for the PillCam capsule was 134.5 seconds.

Both methods detected esophageal varices in 23 patients, with the PillCam detecting small varices in one patient that were missed by EGD. In addition, both detected hypertensive gastropathy in 19 patients.

While a larger trial is needed to confirm these findings, the authors said, “this is the first pilot study showing that the esophageal capsule can be used to screen patients with liver cirrhosis for the presence of varices.”

In the second study, conducted by French scientists, unsedated EGD and capsule endoscopy examinations were conducted on the same day in 21 cirrhotic patients (Endoscopy 2006;38:36–41). The PillCam ESO, which transmits 14 color images per second as it moves through the esophagus, had 81% sensitivity for the diagnosis of esophageal varices, compared with EGD, and had 100% sensitivity for the diagnosis of large varices and/or red signs.

The study, conducted at Edouard Herriot Hospital in Lyon, France, also showed that all 20 patients who swallowed a PillCam (one was unable to do so) preferred it over EGD.

Camera-in-a-capsule technology may be as effective as the more invasive conventional upper endoscopy at detecting esophageal varices, according to tandem studies.

In a pilot trial, American, Israeli, and French investigators compared conventional esophagogastroduodenoscopy (EGD) with the commercially available PillCam ESO.

The targets were esophageal varices, which affect a large majority of patients with cirrhosis and portal hypertension, according to Dr. Glenn M. Eisen and colleagues at Oregon Health and Science University, Portland (Endoscopy 2006;38:31–5).

The study involved 32 patients with cirrhosis who were undergoing clinically indicated EGD for screening or surveillance for esophageal varices. All underwent a PillCam ESO study followed by an EGD within 48 hours. Capsule videos were assessed by an investigator who was blinded to the patients' medical histories and EGD findings. The median esophageal transit time for the PillCam capsule was 134.5 seconds.

Both methods detected esophageal varices in 23 patients, with the PillCam detecting small varices in one patient that were missed by EGD. In addition, both detected hypertensive gastropathy in 19 patients.

While a larger trial is needed to confirm these findings, the authors said, “this is the first pilot study showing that the esophageal capsule can be used to screen patients with liver cirrhosis for the presence of varices.”

In the second study, conducted by French scientists, unsedated EGD and capsule endoscopy examinations were conducted on the same day in 21 cirrhotic patients (Endoscopy 2006;38:36–41). The PillCam ESO, which transmits 14 color images per second as it moves through the esophagus, had 81% sensitivity for the diagnosis of esophageal varices, compared with EGD, and had 100% sensitivity for the diagnosis of large varices and/or red signs.

The study, conducted at Edouard Herriot Hospital in Lyon, France, also showed that all 20 patients who swallowed a PillCam (one was unable to do so) preferred it over EGD.

Camera-in-a-capsule technology may be as effective as the more invasive conventional upper endoscopy at detecting esophageal varices, according to tandem studies.

In a pilot trial, American, Israeli, and French investigators compared conventional esophagogastroduodenoscopy (EGD) with the commercially available PillCam ESO.

The targets were esophageal varices, which affect a large majority of patients with cirrhosis and portal hypertension, according to Dr. Glenn M. Eisen and colleagues at Oregon Health and Science University, Portland (Endoscopy 2006;38:31–5).

The study involved 32 patients with cirrhosis who were undergoing clinically indicated EGD for screening or surveillance for esophageal varices. All underwent a PillCam ESO study followed by an EGD within 48 hours. Capsule videos were assessed by an investigator who was blinded to the patients' medical histories and EGD findings. The median esophageal transit time for the PillCam capsule was 134.5 seconds.

Both methods detected esophageal varices in 23 patients, with the PillCam detecting small varices in one patient that were missed by EGD. In addition, both detected hypertensive gastropathy in 19 patients.

While a larger trial is needed to confirm these findings, the authors said, “this is the first pilot study showing that the esophageal capsule can be used to screen patients with liver cirrhosis for the presence of varices.”

In the second study, conducted by French scientists, unsedated EGD and capsule endoscopy examinations were conducted on the same day in 21 cirrhotic patients (Endoscopy 2006;38:36–41). The PillCam ESO, which transmits 14 color images per second as it moves through the esophagus, had 81% sensitivity for the diagnosis of esophageal varices, compared with EGD, and had 100% sensitivity for the diagnosis of large varices and/or red signs.

The study, conducted at Edouard Herriot Hospital in Lyon, France, also showed that all 20 patients who swallowed a PillCam (one was unable to do so) preferred it over EGD.

MONTREAL — The addition of simvastatin to an oral contraceptive regimen significantly reduces hirsutism and elevated levels of total testosterone in women with polycystic ovary syndrome, according to a study conducted by Dr. Antoni J. Duleba, of Yale University, New Haven, Conn., and associates.

“This is the first report that simvastatin improves a clinical end point of treatment of polycystic ovary syndrome/hirsutism,” Dr. Duleba, the lead investigator, said in an interview.

The data were presented by another investigator in the study, Dr. Beata Banaszewska, at the conjoint annual meeting of the American Society for Reproductive Medicine and the Canadian Fertility and Andrology Society.

Oral contraceptive pills “do reduce testosterone levels, but in this crossover study, we can appreciate that statins have a greater power to this effect,” Dr. Banaszewska, of Poznan University of Medical Sciences in Poland, said at the meeting.

“We still don't have satisfactory medical treatments for PCOS; symptomatic treatments only partly improve the situation, and long term, these patients are at increased risk of cardiovascular problems,” he said.

The study randomized 48 PCOS patients (mean age 24 years) into two treatment groups. One group received oral contraceptive pills (OCP) alone (20-mcg ethinyl estradiol and 150-mcg desogestrel) for 12 weeks, after which 20-mg simvastatin was added to their regimen daily for 12 more weeks. The other group first received the combined drug regimen for 12 weeks and then were given OCP alone for 12 weeks. Clinical, endocrine, and metabolic evaluations were performed at baseline, at cross-over (12 weeks), and at 24 weeks.

“Simvastatin induced a decrease of total testosterone by 18% below the effect of OCP,” Dr. Duleba said. “This effect was paralleled by a 16% decrease of free testosterone below the effect of OCP. We also found that the hirsutism declined, and there was a strong trend toward an improvement in acne.”

A simvastatin-attributable decline of hirsutism was modestly but significantly greater than with OCP alone; this 4% difference was statistically significant.

Kate Johnson of the Montreal Bureau contributed to this report.

'This is the first report that simvastatin improves a clinical end point of treatment' of PCOS/hirsutism. DR. DULEBA

MONTREAL — The addition of simvastatin to an oral contraceptive regimen significantly reduces hirsutism and elevated levels of total testosterone in women with polycystic ovary syndrome, according to a study conducted by Dr. Antoni J. Duleba, of Yale University, New Haven, Conn., and associates.

“This is the first report that simvastatin improves a clinical end point of treatment of polycystic ovary syndrome/hirsutism,” Dr. Duleba, the lead investigator, said in an interview.

The data were presented by another investigator in the study, Dr. Beata Banaszewska, at the conjoint annual meeting of the American Society for Reproductive Medicine and the Canadian Fertility and Andrology Society.

Oral contraceptive pills “do reduce testosterone levels, but in this crossover study, we can appreciate that statins have a greater power to this effect,” Dr. Banaszewska, of Poznan University of Medical Sciences in Poland, said at the meeting.

“We still don't have satisfactory medical treatments for PCOS; symptomatic treatments only partly improve the situation, and long term, these patients are at increased risk of cardiovascular problems,” he said.

The study randomized 48 PCOS patients (mean age 24 years) into two treatment groups. One group received oral contraceptive pills (OCP) alone (20-mcg ethinyl estradiol and 150-mcg desogestrel) for 12 weeks, after which 20-mg simvastatin was added to their regimen daily for 12 more weeks. The other group first received the combined drug regimen for 12 weeks and then were given OCP alone for 12 weeks. Clinical, endocrine, and metabolic evaluations were performed at baseline, at cross-over (12 weeks), and at 24 weeks.

“Simvastatin induced a decrease of total testosterone by 18% below the effect of OCP,” Dr. Duleba said. “This effect was paralleled by a 16% decrease of free testosterone below the effect of OCP. We also found that the hirsutism declined, and there was a strong trend toward an improvement in acne.”

A simvastatin-attributable decline of hirsutism was modestly but significantly greater than with OCP alone; this 4% difference was statistically significant.

Kate Johnson of the Montreal Bureau contributed to this report.

'This is the first report that simvastatin improves a clinical end point of treatment' of PCOS/hirsutism. DR. DULEBA

MONTREAL — The addition of simvastatin to an oral contraceptive regimen significantly reduces hirsutism and elevated levels of total testosterone in women with polycystic ovary syndrome, according to a study conducted by Dr. Antoni J. Duleba, of Yale University, New Haven, Conn., and associates.

“This is the first report that simvastatin improves a clinical end point of treatment of polycystic ovary syndrome/hirsutism,” Dr. Duleba, the lead investigator, said in an interview.

The data were presented by another investigator in the study, Dr. Beata Banaszewska, at the conjoint annual meeting of the American Society for Reproductive Medicine and the Canadian Fertility and Andrology Society.

Oral contraceptive pills “do reduce testosterone levels, but in this crossover study, we can appreciate that statins have a greater power to this effect,” Dr. Banaszewska, of Poznan University of Medical Sciences in Poland, said at the meeting.

“We still don't have satisfactory medical treatments for PCOS; symptomatic treatments only partly improve the situation, and long term, these patients are at increased risk of cardiovascular problems,” he said.

The study randomized 48 PCOS patients (mean age 24 years) into two treatment groups. One group received oral contraceptive pills (OCP) alone (20-mcg ethinyl estradiol and 150-mcg desogestrel) for 12 weeks, after which 20-mg simvastatin was added to their regimen daily for 12 more weeks. The other group first received the combined drug regimen for 12 weeks and then were given OCP alone for 12 weeks. Clinical, endocrine, and metabolic evaluations were performed at baseline, at cross-over (12 weeks), and at 24 weeks.

“Simvastatin induced a decrease of total testosterone by 18% below the effect of OCP,” Dr. Duleba said. “This effect was paralleled by a 16% decrease of free testosterone below the effect of OCP. We also found that the hirsutism declined, and there was a strong trend toward an improvement in acne.”

A simvastatin-attributable decline of hirsutism was modestly but significantly greater than with OCP alone; this 4% difference was statistically significant.

Kate Johnson of the Montreal Bureau contributed to this report.

'This is the first report that simvastatin improves a clinical end point of treatment' of PCOS/hirsutism. DR. DULEBA

Approximately one in six U.S. high school students has asthma, according to the Centers for Disease Control and Prevention.

The CDC examined data from the 2003 national Youth Risk Behavior Survey (YRBS) of public and private school students in grades 9–12 in all 50 states and the District of Columbia.

The CDC noted that 18.9% of students had been told by a doctor or nurse at least once that they had asthma; 16.1% had current asthma; and 37.9% of those with current asthma had a wheezing episode or attack during the 12 months preceding the YRBS.

“These findings underscore the need for health care providers, schools, families, and public health care practitioners to be prepared to respond to asthma-related emergencies and to help students manage their asthma,” said the CDC (MMWR 2005;54:766–7).

The survey used a three-stage cluster sample design to obtain cross-sectional data representative of the nation's high school students. The school, student, and overall response rates were 81%, 83%, and 67%, respectively. The first question “Has a doctor or nurse ever told you that you have asthma?” was answered by 13,553 students. The second question “During the past 12 months, have you had an episode of asthma or an asthma attack?” was answered by 13,232 students. Each student was expected to answer both questions, and 13,222 students did so.

Fewer Hispanic students (15.6%) than black (21.3%) or white (19.3%) reported lifetime asthma. And fewer Hispanic students (12.9%) than black (16.8%) or white (17%) reported current asthma, as did a smaller proportion of 10th-grade students (15%), compared with 9th-grade students (17.5%). In addition, more 9th-grade students with current asthma reported having an attack or episode (45%), compared with 10th (36.4%), 11th (34.6%), and 12th graders (33%). Girls reported higher rates of asthma episodes than did boys (44.5%, compared with 31.1%). All these data reached statistical significance.

These YRBS results differ from those of the 2003 National Health Interview Survey (NHIS) reported by the CDC earlier this year. In that unpublished survey, parents reported 14.5% of their children aged 14–17 years had lifetime asthma; 8.9% had current asthma, and among that group, 57% had an asthma episode or attack during the preceding year. The agency said the differences between the two surveys might be attributable to differences in age (grades 9–12 versus 14–17 years), the fact that data were reported by students and not by parents, and question wording. Further research is needed to better understand the reasons for these differences and their implications for asthma management, the CDC said.

The agency also said it is noteworthy that while other national data sources have revealed black children get asthma more often than do white children, the YRBS survey found no such racial difference for current asthma. Further research also may shed light on why more girls with asthma and more ninth-grade students reported having had an asthma episode or attack during the preceding 12 months.

The YRBS investigators emphasize that their survey has limitations: The data do not include the 5% of adolescents not enrolled in high school; the extent of under- or overreporting of asthma and asthma episodes cannot be determined; and data for Hispanic respondents are derived from a combination of Mexican American, Puerto Rican, and other Hispanic students.

“A primary prevention strategy for asthma does not exist, but asthma can be controlled,” the CDC said. “Schools can help improve asthma management among students whose asthma is not well controlled by providing health services, education, and control of environmental triggers. The CDC, other federal agencies, the National Asthma Education and Prevention Program, and national nongovernmental organizations have developed resources to support asthma management activities at schools. CDC's 'Strategies for Addressing Asthma Within a Coordinated School Health Program' recommends research-based activities for schools to help students manage their asthma.” Management includes providing a written action plan for all asthmatic students, ensuring those students receive education on asthma, and enforcing a schoolwide smoking ban.

Approximately one in six U.S. high school students has asthma, according to the Centers for Disease Control and Prevention.

The CDC examined data from the 2003 national Youth Risk Behavior Survey (YRBS) of public and private school students in grades 9–12 in all 50 states and the District of Columbia.

The CDC noted that 18.9% of students had been told by a doctor or nurse at least once that they had asthma; 16.1% had current asthma; and 37.9% of those with current asthma had a wheezing episode or attack during the 12 months preceding the YRBS.

“These findings underscore the need for health care providers, schools, families, and public health care practitioners to be prepared to respond to asthma-related emergencies and to help students manage their asthma,” said the CDC (MMWR 2005;54:766–7).

The survey used a three-stage cluster sample design to obtain cross-sectional data representative of the nation's high school students. The school, student, and overall response rates were 81%, 83%, and 67%, respectively. The first question “Has a doctor or nurse ever told you that you have asthma?” was answered by 13,553 students. The second question “During the past 12 months, have you had an episode of asthma or an asthma attack?” was answered by 13,232 students. Each student was expected to answer both questions, and 13,222 students did so.

Fewer Hispanic students (15.6%) than black (21.3%) or white (19.3%) reported lifetime asthma. And fewer Hispanic students (12.9%) than black (16.8%) or white (17%) reported current asthma, as did a smaller proportion of 10th-grade students (15%), compared with 9th-grade students (17.5%). In addition, more 9th-grade students with current asthma reported having an attack or episode (45%), compared with 10th (36.4%), 11th (34.6%), and 12th graders (33%). Girls reported higher rates of asthma episodes than did boys (44.5%, compared with 31.1%). All these data reached statistical significance.

These YRBS results differ from those of the 2003 National Health Interview Survey (NHIS) reported by the CDC earlier this year. In that unpublished survey, parents reported 14.5% of their children aged 14–17 years had lifetime asthma; 8.9% had current asthma, and among that group, 57% had an asthma episode or attack during the preceding year. The agency said the differences between the two surveys might be attributable to differences in age (grades 9–12 versus 14–17 years), the fact that data were reported by students and not by parents, and question wording. Further research is needed to better understand the reasons for these differences and their implications for asthma management, the CDC said.

The agency also said it is noteworthy that while other national data sources have revealed black children get asthma more often than do white children, the YRBS survey found no such racial difference for current asthma. Further research also may shed light on why more girls with asthma and more ninth-grade students reported having had an asthma episode or attack during the preceding 12 months.

The YRBS investigators emphasize that their survey has limitations: The data do not include the 5% of adolescents not enrolled in high school; the extent of under- or overreporting of asthma and asthma episodes cannot be determined; and data for Hispanic respondents are derived from a combination of Mexican American, Puerto Rican, and other Hispanic students.

“A primary prevention strategy for asthma does not exist, but asthma can be controlled,” the CDC said. “Schools can help improve asthma management among students whose asthma is not well controlled by providing health services, education, and control of environmental triggers. The CDC, other federal agencies, the National Asthma Education and Prevention Program, and national nongovernmental organizations have developed resources to support asthma management activities at schools. CDC's 'Strategies for Addressing Asthma Within a Coordinated School Health Program' recommends research-based activities for schools to help students manage their asthma.” Management includes providing a written action plan for all asthmatic students, ensuring those students receive education on asthma, and enforcing a schoolwide smoking ban.

Approximately one in six U.S. high school students has asthma, according to the Centers for Disease Control and Prevention.

The CDC examined data from the 2003 national Youth Risk Behavior Survey (YRBS) of public and private school students in grades 9–12 in all 50 states and the District of Columbia.

The CDC noted that 18.9% of students had been told by a doctor or nurse at least once that they had asthma; 16.1% had current asthma; and 37.9% of those with current asthma had a wheezing episode or attack during the 12 months preceding the YRBS.

“These findings underscore the need for health care providers, schools, families, and public health care practitioners to be prepared to respond to asthma-related emergencies and to help students manage their asthma,” said the CDC (MMWR 2005;54:766–7).

The survey used a three-stage cluster sample design to obtain cross-sectional data representative of the nation's high school students. The school, student, and overall response rates were 81%, 83%, and 67%, respectively. The first question “Has a doctor or nurse ever told you that you have asthma?” was answered by 13,553 students. The second question “During the past 12 months, have you had an episode of asthma or an asthma attack?” was answered by 13,232 students. Each student was expected to answer both questions, and 13,222 students did so.

Fewer Hispanic students (15.6%) than black (21.3%) or white (19.3%) reported lifetime asthma. And fewer Hispanic students (12.9%) than black (16.8%) or white (17%) reported current asthma, as did a smaller proportion of 10th-grade students (15%), compared with 9th-grade students (17.5%). In addition, more 9th-grade students with current asthma reported having an attack or episode (45%), compared with 10th (36.4%), 11th (34.6%), and 12th graders (33%). Girls reported higher rates of asthma episodes than did boys (44.5%, compared with 31.1%). All these data reached statistical significance.

These YRBS results differ from those of the 2003 National Health Interview Survey (NHIS) reported by the CDC earlier this year. In that unpublished survey, parents reported 14.5% of their children aged 14–17 years had lifetime asthma; 8.9% had current asthma, and among that group, 57% had an asthma episode or attack during the preceding year. The agency said the differences between the two surveys might be attributable to differences in age (grades 9–12 versus 14–17 years), the fact that data were reported by students and not by parents, and question wording. Further research is needed to better understand the reasons for these differences and their implications for asthma management, the CDC said.

The agency also said it is noteworthy that while other national data sources have revealed black children get asthma more often than do white children, the YRBS survey found no such racial difference for current asthma. Further research also may shed light on why more girls with asthma and more ninth-grade students reported having had an asthma episode or attack during the preceding 12 months.

The YRBS investigators emphasize that their survey has limitations: The data do not include the 5% of adolescents not enrolled in high school; the extent of under- or overreporting of asthma and asthma episodes cannot be determined; and data for Hispanic respondents are derived from a combination of Mexican American, Puerto Rican, and other Hispanic students.

“A primary prevention strategy for asthma does not exist, but asthma can be controlled,” the CDC said. “Schools can help improve asthma management among students whose asthma is not well controlled by providing health services, education, and control of environmental triggers. The CDC, other federal agencies, the National Asthma Education and Prevention Program, and national nongovernmental organizations have developed resources to support asthma management activities at schools. CDC's 'Strategies for Addressing Asthma Within a Coordinated School Health Program' recommends research-based activities for schools to help students manage their asthma.” Management includes providing a written action plan for all asthmatic students, ensuring those students receive education on asthma, and enforcing a schoolwide smoking ban.

Live, attenuated poliovirus vaccine strains do not persist for extended periods after the oral vaccine is replaced by the inactivated poliovirus vaccine in a developed country with a temperate climate, Q. Sue Huang, Ph.D., and colleagues reported.

The study is part of an ongoing effort to develop strategies on when and how to stop oral poliovirus vaccine (OPV) immunization once the disease is eradicated, said Dr. Huang of the Institute of Environmental Science and Research, Porirua, New Zealand (Lancet 2005;366:394–6).

The authors explained that after OPV vaccination, poliovirus is excreted by healthy children for 2–3 months and the virus' persistence in populations is limited. “Reports from several developing countries, though, indicate that circulating neurovirulent vaccine-derived poliovirus strains can be sustained for extended periods and cause poliomyelitis when population immunity is low.”

When in 2002 New Zealand's immunization schedule changed from OPV to inactivated poliovirus vaccine (IPV), Dr. Huang's team began to monitor the persistence of OPV strains excreted by the last cohorts of immunized children.

“We did systematic, population-based surveillance for OPV virus circulation and evolution before, during, and after the OPV/IPV switch with combined pediatric inpatient, acute flaccid paralysis, enterovirus laboratory, and environmental surveillance systems,” the investigators said.

The first three methods targeted people most likely to be excreting poliovirus, but only environmental surveillance—obtaining composite samples from sewage systems that serve 28% of the population—was able to detect polioviruses 2 months after the OPV to IPV switch.

“Before the OPV/IPV switch, the poliovirus isolation rate was 94%. This proportion decreased after the switch, but not as rapidly as with other surveillance methods. The decline was maintained in the posttransitional period (April 2002 to April 2003) such that, after May 2002, polioviruses were only detected once every 3 months,” the investigators said.

Enterovirus (pediatric inpatient) surveillance found no poliovirus isolates in stool samples 1 month after the vaccine protocol change.

Molecular sequencing traced all postswitch isolates back to OPV. “Since polioviruses evolve at a constant rate of 1% nucleotide substitutions per year, environmental isolates 6–12 months post switch with 99.7%–100% sequence homology to parental Sabin strains infer that these viruses were derived from OPV administered 1–3 months previously,” said Dr Huang and associates.

The scientists reckoned that these viruses most likely originated in recently vaccinated children or their close contacts from an OPV-using country, which shows that New Zealand “remains vulnerable to vaccine or wild-type virus importation.”

They said that it's important that the study be repeated in tropical, developing countries where transmission of OPV viruses is likely to be more intense. “The findings of such studies are vital to formulate polio immunization policies in the postcertification era. Simultaneous global cessation of OPV after a mass immunization campaign to maximize population immunity and minimize vaccine-derived poliovirus circulation could be adopted if there is minimum risk of sustained vaccine-derived poliovirus circulation.”

In an accompanying editorial, Calman MacLennan, M.D., and Jenny MacLennan, M.D., of the University of Malawi, Blantyre, said that while this study suggests that replacement of OPV with IPV can, in an environment like New Zealand's, greatly reduce, and perhaps prevent, persistence of vaccine-related polioviruses, “these findings do not address what happens if vaccination with OPV is stopped without switching to IPV and whether similar results would be obtained in tropical developing countries (Lancet 2005;366:351–3).

Live, attenuated poliovirus vaccine strains do not persist for extended periods after the oral vaccine is replaced by the inactivated poliovirus vaccine in a developed country with a temperate climate, Q. Sue Huang, Ph.D., and colleagues reported.

The study is part of an ongoing effort to develop strategies on when and how to stop oral poliovirus vaccine (OPV) immunization once the disease is eradicated, said Dr. Huang of the Institute of Environmental Science and Research, Porirua, New Zealand (Lancet 2005;366:394–6).

The authors explained that after OPV vaccination, poliovirus is excreted by healthy children for 2–3 months and the virus' persistence in populations is limited. “Reports from several developing countries, though, indicate that circulating neurovirulent vaccine-derived poliovirus strains can be sustained for extended periods and cause poliomyelitis when population immunity is low.”

When in 2002 New Zealand's immunization schedule changed from OPV to inactivated poliovirus vaccine (IPV), Dr. Huang's team began to monitor the persistence of OPV strains excreted by the last cohorts of immunized children.

“We did systematic, population-based surveillance for OPV virus circulation and evolution before, during, and after the OPV/IPV switch with combined pediatric inpatient, acute flaccid paralysis, enterovirus laboratory, and environmental surveillance systems,” the investigators said.

The first three methods targeted people most likely to be excreting poliovirus, but only environmental surveillance—obtaining composite samples from sewage systems that serve 28% of the population—was able to detect polioviruses 2 months after the OPV to IPV switch.

“Before the OPV/IPV switch, the poliovirus isolation rate was 94%. This proportion decreased after the switch, but not as rapidly as with other surveillance methods. The decline was maintained in the posttransitional period (April 2002 to April 2003) such that, after May 2002, polioviruses were only detected once every 3 months,” the investigators said.

Enterovirus (pediatric inpatient) surveillance found no poliovirus isolates in stool samples 1 month after the vaccine protocol change.

Molecular sequencing traced all postswitch isolates back to OPV. “Since polioviruses evolve at a constant rate of 1% nucleotide substitutions per year, environmental isolates 6–12 months post switch with 99.7%–100% sequence homology to parental Sabin strains infer that these viruses were derived from OPV administered 1–3 months previously,” said Dr Huang and associates.

The scientists reckoned that these viruses most likely originated in recently vaccinated children or their close contacts from an OPV-using country, which shows that New Zealand “remains vulnerable to vaccine or wild-type virus importation.”

They said that it's important that the study be repeated in tropical, developing countries where transmission of OPV viruses is likely to be more intense. “The findings of such studies are vital to formulate polio immunization policies in the postcertification era. Simultaneous global cessation of OPV after a mass immunization campaign to maximize population immunity and minimize vaccine-derived poliovirus circulation could be adopted if there is minimum risk of sustained vaccine-derived poliovirus circulation.”

In an accompanying editorial, Calman MacLennan, M.D., and Jenny MacLennan, M.D., of the University of Malawi, Blantyre, said that while this study suggests that replacement of OPV with IPV can, in an environment like New Zealand's, greatly reduce, and perhaps prevent, persistence of vaccine-related polioviruses, “these findings do not address what happens if vaccination with OPV is stopped without switching to IPV and whether similar results would be obtained in tropical developing countries (Lancet 2005;366:351–3).

Live, attenuated poliovirus vaccine strains do not persist for extended periods after the oral vaccine is replaced by the inactivated poliovirus vaccine in a developed country with a temperate climate, Q. Sue Huang, Ph.D., and colleagues reported.

The study is part of an ongoing effort to develop strategies on when and how to stop oral poliovirus vaccine (OPV) immunization once the disease is eradicated, said Dr. Huang of the Institute of Environmental Science and Research, Porirua, New Zealand (Lancet 2005;366:394–6).

The authors explained that after OPV vaccination, poliovirus is excreted by healthy children for 2–3 months and the virus' persistence in populations is limited. “Reports from several developing countries, though, indicate that circulating neurovirulent vaccine-derived poliovirus strains can be sustained for extended periods and cause poliomyelitis when population immunity is low.”

When in 2002 New Zealand's immunization schedule changed from OPV to inactivated poliovirus vaccine (IPV), Dr. Huang's team began to monitor the persistence of OPV strains excreted by the last cohorts of immunized children.

“We did systematic, population-based surveillance for OPV virus circulation and evolution before, during, and after the OPV/IPV switch with combined pediatric inpatient, acute flaccid paralysis, enterovirus laboratory, and environmental surveillance systems,” the investigators said.

The first three methods targeted people most likely to be excreting poliovirus, but only environmental surveillance—obtaining composite samples from sewage systems that serve 28% of the population—was able to detect polioviruses 2 months after the OPV to IPV switch.

“Before the OPV/IPV switch, the poliovirus isolation rate was 94%. This proportion decreased after the switch, but not as rapidly as with other surveillance methods. The decline was maintained in the posttransitional period (April 2002 to April 2003) such that, after May 2002, polioviruses were only detected once every 3 months,” the investigators said.

Enterovirus (pediatric inpatient) surveillance found no poliovirus isolates in stool samples 1 month after the vaccine protocol change.

Molecular sequencing traced all postswitch isolates back to OPV. “Since polioviruses evolve at a constant rate of 1% nucleotide substitutions per year, environmental isolates 6–12 months post switch with 99.7%–100% sequence homology to parental Sabin strains infer that these viruses were derived from OPV administered 1–3 months previously,” said Dr Huang and associates.

The scientists reckoned that these viruses most likely originated in recently vaccinated children or their close contacts from an OPV-using country, which shows that New Zealand “remains vulnerable to vaccine or wild-type virus importation.”

They said that it's important that the study be repeated in tropical, developing countries where transmission of OPV viruses is likely to be more intense. “The findings of such studies are vital to formulate polio immunization policies in the postcertification era. Simultaneous global cessation of OPV after a mass immunization campaign to maximize population immunity and minimize vaccine-derived poliovirus circulation could be adopted if there is minimum risk of sustained vaccine-derived poliovirus circulation.”

In an accompanying editorial, Calman MacLennan, M.D., and Jenny MacLennan, M.D., of the University of Malawi, Blantyre, said that while this study suggests that replacement of OPV with IPV can, in an environment like New Zealand's, greatly reduce, and perhaps prevent, persistence of vaccine-related polioviruses, “these findings do not address what happens if vaccination with OPV is stopped without switching to IPV and whether similar results would be obtained in tropical developing countries (Lancet 2005;366:351–3).

Cesarean section in a first pregnancy may reduce a woman's risk of having pelvic floor surgery later in life, reported Ramalingam Uma, M.B., and colleagues at the University of Dundee, Scotland.

The researchers said their study was prompted by the increasing attention to pelvic floor morbidity following childbirth, and by indications that cesarean section may be protective against damage to the pelvic floor support structures and impairment of pelvic floor innervation that can occur during vaginal delivery.

The nested case-control study of first-time mothers was drawn from a population of 7,556 women who had given birth in the hospital between 1952 and 1966. Of these women, 5% underwent pelvic floor surgery in later years (BJOG 2005;112:1043–6).

On univariate analysis, cesarean section (odds ratio 0.24) and greater gestational age at birth (OR 0.20) were associated with a reduced risk of pelvic floor surgery, compared with spontaneous vaginal delivery. In the final multivariate model, only cesarean section was associated with reduced odds of future surgery (OR 0.16).

Subgroup analyses comparing the 61 elective and 68 emergency cesarean sections suggested that both were protective against pelvic floor surgery, compared with spontaneous vaginal delivery (OR of 0.19 and 0.29, respectively).

Dr. Uma and colleagues caution that “the absolute risk of pelvic floor surgery in relation to mode of delivery needs to be put in the context of the adverse effect of pregnancy itself. It has been reported that 46% of nullipara have pelvic organ prolapse at 36 weeks antepartum. … Cesarean section may reduce the risk of pelvic floor surgery relating to the mode of delivery but it will not eliminate the risks associated with pregnancy itself.”

In contrast to previous studies, this analysis did not find an association between forceps delivery and increased risk of pelvic floor surgery.

Cesarean section in a first pregnancy may reduce a woman's risk of having pelvic floor surgery later in life, reported Ramalingam Uma, M.B., and colleagues at the University of Dundee, Scotland.

The researchers said their study was prompted by the increasing attention to pelvic floor morbidity following childbirth, and by indications that cesarean section may be protective against damage to the pelvic floor support structures and impairment of pelvic floor innervation that can occur during vaginal delivery.

The nested case-control study of first-time mothers was drawn from a population of 7,556 women who had given birth in the hospital between 1952 and 1966. Of these women, 5% underwent pelvic floor surgery in later years (BJOG 2005;112:1043–6).

On univariate analysis, cesarean section (odds ratio 0.24) and greater gestational age at birth (OR 0.20) were associated with a reduced risk of pelvic floor surgery, compared with spontaneous vaginal delivery. In the final multivariate model, only cesarean section was associated with reduced odds of future surgery (OR 0.16).

Subgroup analyses comparing the 61 elective and 68 emergency cesarean sections suggested that both were protective against pelvic floor surgery, compared with spontaneous vaginal delivery (OR of 0.19 and 0.29, respectively).

Dr. Uma and colleagues caution that “the absolute risk of pelvic floor surgery in relation to mode of delivery needs to be put in the context of the adverse effect of pregnancy itself. It has been reported that 46% of nullipara have pelvic organ prolapse at 36 weeks antepartum. … Cesarean section may reduce the risk of pelvic floor surgery relating to the mode of delivery but it will not eliminate the risks associated with pregnancy itself.”

In contrast to previous studies, this analysis did not find an association between forceps delivery and increased risk of pelvic floor surgery.

Cesarean section in a first pregnancy may reduce a woman's risk of having pelvic floor surgery later in life, reported Ramalingam Uma, M.B., and colleagues at the University of Dundee, Scotland.

The researchers said their study was prompted by the increasing attention to pelvic floor morbidity following childbirth, and by indications that cesarean section may be protective against damage to the pelvic floor support structures and impairment of pelvic floor innervation that can occur during vaginal delivery.

The nested case-control study of first-time mothers was drawn from a population of 7,556 women who had given birth in the hospital between 1952 and 1966. Of these women, 5% underwent pelvic floor surgery in later years (BJOG 2005;112:1043–6).

On univariate analysis, cesarean section (odds ratio 0.24) and greater gestational age at birth (OR 0.20) were associated with a reduced risk of pelvic floor surgery, compared with spontaneous vaginal delivery. In the final multivariate model, only cesarean section was associated with reduced odds of future surgery (OR 0.16).

Subgroup analyses comparing the 61 elective and 68 emergency cesarean sections suggested that both were protective against pelvic floor surgery, compared with spontaneous vaginal delivery (OR of 0.19 and 0.29, respectively).

Dr. Uma and colleagues caution that “the absolute risk of pelvic floor surgery in relation to mode of delivery needs to be put in the context of the adverse effect of pregnancy itself. It has been reported that 46% of nullipara have pelvic organ prolapse at 36 weeks antepartum. … Cesarean section may reduce the risk of pelvic floor surgery relating to the mode of delivery but it will not eliminate the risks associated with pregnancy itself.”

In contrast to previous studies, this analysis did not find an association between forceps delivery and increased risk of pelvic floor surgery.

A pregnant woman's exposure to secondhand cigarette smoke may be just as risky to the fetus as is active smoking, according to a pooled data reanalysis by Stephen G. Grant, Ph.D., of the University of Pittsburgh.

“This [new] analysis shows not only that smoking during pregnancy causes genetic damage in the developing fetus that can be detected at birth, but also that passive, or secondary, exposure causes just as much damage as active smoking, and it's the same kind of damage,” Dr. Grant said in a statement.

“The women who go to the trouble of quitting smoking feel they have taken care of the problem,” he said in an interview. “This is a cautionary exercise in which we say women have to change their lifestyles in other ways” such as having their husbands quit smoking and not going outside with their friends on smoke breaks even if they don't smoke themselves. “You have to protect your baby from passive exposure as much as from active smoking,” he said.

The study examined data from two contradictory studies published in the mid-1990s on rates of mutation at the HPRT locus (a measure of in vivo mutagenesis) in newborn cord blood samples. Compared with samples from babies who had not been exposed to smoke in utero, exposed babies had significantly higher mutation rates. There were no significant differences in the levels of induced mutation among children of exposed women (active smokers, women who had quit smoking when they found out they were pregnant, and women who were only passively exposed to smoke).

In the pooled data, the median HPRT mutation frequencies for actively and passively smoking moms was identical at 0.87 (BMC Pediatr. 2005;5:20 [Epub ahead of print]).

A pregnant woman's exposure to secondhand cigarette smoke may be just as risky to the fetus as is active smoking, according to a pooled data reanalysis by Stephen G. Grant, Ph.D., of the University of Pittsburgh.

“This [new] analysis shows not only that smoking during pregnancy causes genetic damage in the developing fetus that can be detected at birth, but also that passive, or secondary, exposure causes just as much damage as active smoking, and it's the same kind of damage,” Dr. Grant said in a statement.

“The women who go to the trouble of quitting smoking feel they have taken care of the problem,” he said in an interview. “This is a cautionary exercise in which we say women have to change their lifestyles in other ways” such as having their husbands quit smoking and not going outside with their friends on smoke breaks even if they don't smoke themselves. “You have to protect your baby from passive exposure as much as from active smoking,” he said.

The study examined data from two contradictory studies published in the mid-1990s on rates of mutation at the HPRT locus (a measure of in vivo mutagenesis) in newborn cord blood samples. Compared with samples from babies who had not been exposed to smoke in utero, exposed babies had significantly higher mutation rates. There were no significant differences in the levels of induced mutation among children of exposed women (active smokers, women who had quit smoking when they found out they were pregnant, and women who were only passively exposed to smoke).

In the pooled data, the median HPRT mutation frequencies for actively and passively smoking moms was identical at 0.87 (BMC Pediatr. 2005;5:20 [Epub ahead of print]).

A pregnant woman's exposure to secondhand cigarette smoke may be just as risky to the fetus as is active smoking, according to a pooled data reanalysis by Stephen G. Grant, Ph.D., of the University of Pittsburgh.

“This [new] analysis shows not only that smoking during pregnancy causes genetic damage in the developing fetus that can be detected at birth, but also that passive, or secondary, exposure causes just as much damage as active smoking, and it's the same kind of damage,” Dr. Grant said in a statement.

“The women who go to the trouble of quitting smoking feel they have taken care of the problem,” he said in an interview. “This is a cautionary exercise in which we say women have to change their lifestyles in other ways” such as having their husbands quit smoking and not going outside with their friends on smoke breaks even if they don't smoke themselves. “You have to protect your baby from passive exposure as much as from active smoking,” he said.

The study examined data from two contradictory studies published in the mid-1990s on rates of mutation at the HPRT locus (a measure of in vivo mutagenesis) in newborn cord blood samples. Compared with samples from babies who had not been exposed to smoke in utero, exposed babies had significantly higher mutation rates. There were no significant differences in the levels of induced mutation among children of exposed women (active smokers, women who had quit smoking when they found out they were pregnant, and women who were only passively exposed to smoke).

In the pooled data, the median HPRT mutation frequencies for actively and passively smoking moms was identical at 0.87 (BMC Pediatr. 2005;5:20 [Epub ahead of print]).

Rabies should be part of the differential diagnosis of any patient hospitalized with encephalitis of unknown etiology, and rabies should be considered in people who have been bitten by a dog, especially if the bite occurs in a country where canine rabies is enzootic, according to the Centers for Disease Control and Prevention in Atlanta.

CDC investigators stressed the importance of early diagnosis and treatment of rabies, and underscored the point by describing a case of rabies that occurred last year in Florida (MMWR 2005;54:767–9).

In February 2004, a 41-year-old man died after a 4-day hospitalization and 8 months after being bitten by a dog in Haiti. From the time he was bitten to the onset of symptoms 8 months later, the man reportedly was in normal health and felt well, said Tammy Blankenship, M.D., of the Broward County Health Department in Ft. Lauderdale.

A diagnosis of rabies was considered on the day before his death, but no antemortem samples were obtained for testing. On postmortem, the medical examiner described cytoplasmic inclusions consistent with Negri bodies. Postmortem samples of fixed brain tissue were sent to the CDC, where laboratory testing confirmed a diagnosis of rabies.

“The man arrived at the hospital emergency department with a 2-day history of dysphagia accompanied by hyperventilation and agitation when he attempted to swallow liquids. The problem had worsened by the time of admission; he was noted as 'almost phobic' to liquids. The patient reported having had a brief period of mild fever. He was able to swallow soft, solid food and did not complain of throat pain or discomfort,” the CDC reported.

On the day the man was admitted to hospital, a neurology consultant concluded that the dysphasia etiology was unknown and recommended infectious disease, gastrointestinal, and pulmonary consultations.

On his third day of hospitalization, the patient had a consistent fever of 103° F and an elevated white blood cell count of 14.5/μL. An infectious disease consultant recommended a lumbar puncture and testing for viral illness, especially rabies. The patient's wife said that her husband had been bitten on the fingertip by a dog while he was visiting Haiti 8 months earlier. That the dog was still alive could not be confirmed.

On the fourth day of hospitalization, the patient experienced diplopia, became decreasingly responsive, went into cardiopulmonary arrest, and died.

“In the United States, mandatory vaccination and stray-dog control programs have virtually eliminated circulation of any canine rabies-virus variant among dogs. In comparison, occurrence of rabies in dogs remains a problem in Haiti and other developing countries,” the CDC said.

The agency suggested that travelers avoid contact with dogs and other animals, and recommended rabies preexposure prophylaxis for those planning to stay 30 or more days in remote areas without access to medical care.

Health care professionals should keep in mind that tests for rabies are available at CDC and can be arranged through state health departments. “With the recent report from Wisconsin of a survivor of clinical rabies, rapid diagnosis of rabies is even more critical to managing a patient's clinical course, despite a poor prognosis,” the CDC said. “In addition to enabling consideration of novel interventions, advantages of early diagnosis include prompt implementation of … infection control measures, thereby limiting the number of persons exposed or potentially exposed who require postexposure prophylaxis.”

The CDC reported 8 cases of rabies in 2004 (including 4 transplant-associated cases and 1 involving an immigrant), the highest number of human rabies cases reported since 10 were identified in 1956.

Rabies should be part of the differential diagnosis of any patient hospitalized with encephalitis of unknown etiology, and rabies should be considered in people who have been bitten by a dog, especially if the bite occurs in a country where canine rabies is enzootic, according to the Centers for Disease Control and Prevention in Atlanta.

CDC investigators stressed the importance of early diagnosis and treatment of rabies, and underscored the point by describing a case of rabies that occurred last year in Florida (MMWR 2005;54:767–9).

In February 2004, a 41-year-old man died after a 4-day hospitalization and 8 months after being bitten by a dog in Haiti. From the time he was bitten to the onset of symptoms 8 months later, the man reportedly was in normal health and felt well, said Tammy Blankenship, M.D., of the Broward County Health Department in Ft. Lauderdale.

A diagnosis of rabies was considered on the day before his death, but no antemortem samples were obtained for testing. On postmortem, the medical examiner described cytoplasmic inclusions consistent with Negri bodies. Postmortem samples of fixed brain tissue were sent to the CDC, where laboratory testing confirmed a diagnosis of rabies.

“The man arrived at the hospital emergency department with a 2-day history of dysphagia accompanied by hyperventilation and agitation when he attempted to swallow liquids. The problem had worsened by the time of admission; he was noted as 'almost phobic' to liquids. The patient reported having had a brief period of mild fever. He was able to swallow soft, solid food and did not complain of throat pain or discomfort,” the CDC reported.

On the day the man was admitted to hospital, a neurology consultant concluded that the dysphasia etiology was unknown and recommended infectious disease, gastrointestinal, and pulmonary consultations.

On his third day of hospitalization, the patient had a consistent fever of 103° F and an elevated white blood cell count of 14.5/μL. An infectious disease consultant recommended a lumbar puncture and testing for viral illness, especially rabies. The patient's wife said that her husband had been bitten on the fingertip by a dog while he was visiting Haiti 8 months earlier. That the dog was still alive could not be confirmed.

On the fourth day of hospitalization, the patient experienced diplopia, became decreasingly responsive, went into cardiopulmonary arrest, and died.

“In the United States, mandatory vaccination and stray-dog control programs have virtually eliminated circulation of any canine rabies-virus variant among dogs. In comparison, occurrence of rabies in dogs remains a problem in Haiti and other developing countries,” the CDC said.

The agency suggested that travelers avoid contact with dogs and other animals, and recommended rabies preexposure prophylaxis for those planning to stay 30 or more days in remote areas without access to medical care.

Health care professionals should keep in mind that tests for rabies are available at CDC and can be arranged through state health departments. “With the recent report from Wisconsin of a survivor of clinical rabies, rapid diagnosis of rabies is even more critical to managing a patient's clinical course, despite a poor prognosis,” the CDC said. “In addition to enabling consideration of novel interventions, advantages of early diagnosis include prompt implementation of … infection control measures, thereby limiting the number of persons exposed or potentially exposed who require postexposure prophylaxis.”

The CDC reported 8 cases of rabies in 2004 (including 4 transplant-associated cases and 1 involving an immigrant), the highest number of human rabies cases reported since 10 were identified in 1956.

Rabies should be part of the differential diagnosis of any patient hospitalized with encephalitis of unknown etiology, and rabies should be considered in people who have been bitten by a dog, especially if the bite occurs in a country where canine rabies is enzootic, according to the Centers for Disease Control and Prevention in Atlanta.

CDC investigators stressed the importance of early diagnosis and treatment of rabies, and underscored the point by describing a case of rabies that occurred last year in Florida (MMWR 2005;54:767–9).

In February 2004, a 41-year-old man died after a 4-day hospitalization and 8 months after being bitten by a dog in Haiti. From the time he was bitten to the onset of symptoms 8 months later, the man reportedly was in normal health and felt well, said Tammy Blankenship, M.D., of the Broward County Health Department in Ft. Lauderdale.

A diagnosis of rabies was considered on the day before his death, but no antemortem samples were obtained for testing. On postmortem, the medical examiner described cytoplasmic inclusions consistent with Negri bodies. Postmortem samples of fixed brain tissue were sent to the CDC, where laboratory testing confirmed a diagnosis of rabies.

“The man arrived at the hospital emergency department with a 2-day history of dysphagia accompanied by hyperventilation and agitation when he attempted to swallow liquids. The problem had worsened by the time of admission; he was noted as 'almost phobic' to liquids. The patient reported having had a brief period of mild fever. He was able to swallow soft, solid food and did not complain of throat pain or discomfort,” the CDC reported.

On the day the man was admitted to hospital, a neurology consultant concluded that the dysphasia etiology was unknown and recommended infectious disease, gastrointestinal, and pulmonary consultations.

On his third day of hospitalization, the patient had a consistent fever of 103° F and an elevated white blood cell count of 14.5/μL. An infectious disease consultant recommended a lumbar puncture and testing for viral illness, especially rabies. The patient's wife said that her husband had been bitten on the fingertip by a dog while he was visiting Haiti 8 months earlier. That the dog was still alive could not be confirmed.

On the fourth day of hospitalization, the patient experienced diplopia, became decreasingly responsive, went into cardiopulmonary arrest, and died.

“In the United States, mandatory vaccination and stray-dog control programs have virtually eliminated circulation of any canine rabies-virus variant among dogs. In comparison, occurrence of rabies in dogs remains a problem in Haiti and other developing countries,” the CDC said.

The agency suggested that travelers avoid contact with dogs and other animals, and recommended rabies preexposure prophylaxis for those planning to stay 30 or more days in remote areas without access to medical care.

Health care professionals should keep in mind that tests for rabies are available at CDC and can be arranged through state health departments. “With the recent report from Wisconsin of a survivor of clinical rabies, rapid diagnosis of rabies is even more critical to managing a patient's clinical course, despite a poor prognosis,” the CDC said. “In addition to enabling consideration of novel interventions, advantages of early diagnosis include prompt implementation of … infection control measures, thereby limiting the number of persons exposed or potentially exposed who require postexposure prophylaxis.”

The CDC reported 8 cases of rabies in 2004 (including 4 transplant-associated cases and 1 involving an immigrant), the highest number of human rabies cases reported since 10 were identified in 1956.

Immunization coverage of teenagers and adults in 2004 fell short of the coverage achieved in children, the Centers for Disease Control and Prevention reported at a press briefing.

Data from the 2004 National Immunization Survey show that 80.9% of children aged 19–35 months received the recommended vaccinations (diphtheria and tetanus toxoids with acellular pertussis, polio, measles, Haemophilus influenzae type b, and hepatitis B), said Stephen Cochi, M.D., acting director of CDC's National Immunization Program. The 80.9% rate in 2004 surpassed the Healthy People 2010 goal of 80% for that age group.

David A. Neumann, Ph.D., executive director of the National Partnership for Immunization, said efforts to immunize adolescents are bearing fruit, but there's a lot of work to be done.

About 25% of U.S. adolescents have not received at least one of the vaccines recommended for them (hepatitis B, MMR, varicella, meningococcal, or the combination DTP vaccine). “Also, in recent years, we've seen an upsurge of pertussis among adolescents. We find that pertussis immunity wanes during adolescence, and [so] this year we have two new licensed vaccines that will add a pertussis booster for use by adolescents and adults,” Dr. Neumann said.

The status of adult immunization in the United States is less encouraging, he said. “Despite the availability, value, and effectiveness of vaccines we have for adults, the statistics that we have are very disappointing. We are not meeting the nation's public health targets for protecting adults against vaccine-preventable diseases. For example, at best, we immunize barely 70% of adults 65 years and older against influenza each year.”

Only about 48% of African-American seniors and 58% of Hispanic seniors get flu shots, while the Healthy People 2010 target is to have 90% of seniors immunized each year against influenza. Of high-risk adults, only about 37% of those aged 50–64 years and 24% of those aged 18–49 get immunized. The 2010 target for this group is 60% coverage. Finally, on an annualized basis, about 40% of health care workers are immunized against influenza.

“The bottom line seems to be that we lack an appropriate infrastructure to support adult immunization,” Dr. Neumann said at the briefing.

“So how can we create an infrastructure?” he asked. “We and others in the public health community can look for increased support for the public purchase and distribution of influenza vaccine for underinsured and uninsured adults. We can look for leadership from the federal government to [ensure] that influenza and pneumococcal vaccines are part of the first dollar benefits under the federal employee health benefit program. We can work for the inclusion of beneficiary and health care worker immunization as measurable quality indicators for the Centers for Medicare and Medicaid Services. We also can encourage the CMS to pursue the inclusion of health care worker immunization as a criterion for accreditation of health care facilities throughout the nation.”

Otherwise, he envisions a beefed-up adult immunization infrastructure as being a copy of that used for children. “We would see health care providers being proactive and providing immunization services to their patients just as pediatricians now do for children. Currently in the United States, public money purchases vaccines for about half of children. … There's little that can come close in terms of adult immunization.”

Adult education also is neglected, according to Dr. Neumann. “One of my favorite ways of expressing that is that many of us in the baby boom generation think that we're immortal, and we do well for 20 or 30 years and, boom! We end up with chest pains, and we go see a cardiologist. Well, the cardiologist will take care of your cardiac issues, but the cardiologist isn't even thinking about influenza or pneumococcal immunization, even if you're in a high-risk group. So there's a lot of provider education that we need to do as well, through CME and other programs.”

Immunization coverage of teenagers and adults in 2004 fell short of the coverage achieved in children, the Centers for Disease Control and Prevention reported at a press briefing.

Data from the 2004 National Immunization Survey show that 80.9% of children aged 19–35 months received the recommended vaccinations (diphtheria and tetanus toxoids with acellular pertussis, polio, measles, Haemophilus influenzae type b, and hepatitis B), said Stephen Cochi, M.D., acting director of CDC's National Immunization Program. The 80.9% rate in 2004 surpassed the Healthy People 2010 goal of 80% for that age group.

David A. Neumann, Ph.D., executive director of the National Partnership for Immunization, said efforts to immunize adolescents are bearing fruit, but there's a lot of work to be done.

About 25% of U.S. adolescents have not received at least one of the vaccines recommended for them (hepatitis B, MMR, varicella, meningococcal, or the combination DTP vaccine). “Also, in recent years, we've seen an upsurge of pertussis among adolescents. We find that pertussis immunity wanes during adolescence, and [so] this year we have two new licensed vaccines that will add a pertussis booster for use by adolescents and adults,” Dr. Neumann said.

The status of adult immunization in the United States is less encouraging, he said. “Despite the availability, value, and effectiveness of vaccines we have for adults, the statistics that we have are very disappointing. We are not meeting the nation's public health targets for protecting adults against vaccine-preventable diseases. For example, at best, we immunize barely 70% of adults 65 years and older against influenza each year.”

Only about 48% of African-American seniors and 58% of Hispanic seniors get flu shots, while the Healthy People 2010 target is to have 90% of seniors immunized each year against influenza. Of high-risk adults, only about 37% of those aged 50–64 years and 24% of those aged 18–49 get immunized. The 2010 target for this group is 60% coverage. Finally, on an annualized basis, about 40% of health care workers are immunized against influenza.

“The bottom line seems to be that we lack an appropriate infrastructure to support adult immunization,” Dr. Neumann said at the briefing.

“So how can we create an infrastructure?” he asked. “We and others in the public health community can look for increased support for the public purchase and distribution of influenza vaccine for underinsured and uninsured adults. We can look for leadership from the federal government to [ensure] that influenza and pneumococcal vaccines are part of the first dollar benefits under the federal employee health benefit program. We can work for the inclusion of beneficiary and health care worker immunization as measurable quality indicators for the Centers for Medicare and Medicaid Services. We also can encourage the CMS to pursue the inclusion of health care worker immunization as a criterion for accreditation of health care facilities throughout the nation.”

Otherwise, he envisions a beefed-up adult immunization infrastructure as being a copy of that used for children. “We would see health care providers being proactive and providing immunization services to their patients just as pediatricians now do for children. Currently in the United States, public money purchases vaccines for about half of children. … There's little that can come close in terms of adult immunization.”

Adult education also is neglected, according to Dr. Neumann. “One of my favorite ways of expressing that is that many of us in the baby boom generation think that we're immortal, and we do well for 20 or 30 years and, boom! We end up with chest pains, and we go see a cardiologist. Well, the cardiologist will take care of your cardiac issues, but the cardiologist isn't even thinking about influenza or pneumococcal immunization, even if you're in a high-risk group. So there's a lot of provider education that we need to do as well, through CME and other programs.”

Immunization coverage of teenagers and adults in 2004 fell short of the coverage achieved in children, the Centers for Disease Control and Prevention reported at a press briefing.

Data from the 2004 National Immunization Survey show that 80.9% of children aged 19–35 months received the recommended vaccinations (diphtheria and tetanus toxoids with acellular pertussis, polio, measles, Haemophilus influenzae type b, and hepatitis B), said Stephen Cochi, M.D., acting director of CDC's National Immunization Program. The 80.9% rate in 2004 surpassed the Healthy People 2010 goal of 80% for that age group.

David A. Neumann, Ph.D., executive director of the National Partnership for Immunization, said efforts to immunize adolescents are bearing fruit, but there's a lot of work to be done.

About 25% of U.S. adolescents have not received at least one of the vaccines recommended for them (hepatitis B, MMR, varicella, meningococcal, or the combination DTP vaccine). “Also, in recent years, we've seen an upsurge of pertussis among adolescents. We find that pertussis immunity wanes during adolescence, and [so] this year we have two new licensed vaccines that will add a pertussis booster for use by adolescents and adults,” Dr. Neumann said.

The status of adult immunization in the United States is less encouraging, he said. “Despite the availability, value, and effectiveness of vaccines we have for adults, the statistics that we have are very disappointing. We are not meeting the nation's public health targets for protecting adults against vaccine-preventable diseases. For example, at best, we immunize barely 70% of adults 65 years and older against influenza each year.”

Only about 48% of African-American seniors and 58% of Hispanic seniors get flu shots, while the Healthy People 2010 target is to have 90% of seniors immunized each year against influenza. Of high-risk adults, only about 37% of those aged 50–64 years and 24% of those aged 18–49 get immunized. The 2010 target for this group is 60% coverage. Finally, on an annualized basis, about 40% of health care workers are immunized against influenza.

“The bottom line seems to be that we lack an appropriate infrastructure to support adult immunization,” Dr. Neumann said at the briefing.

“So how can we create an infrastructure?” he asked. “We and others in the public health community can look for increased support for the public purchase and distribution of influenza vaccine for underinsured and uninsured adults. We can look for leadership from the federal government to [ensure] that influenza and pneumococcal vaccines are part of the first dollar benefits under the federal employee health benefit program. We can work for the inclusion of beneficiary and health care worker immunization as measurable quality indicators for the Centers for Medicare and Medicaid Services. We also can encourage the CMS to pursue the inclusion of health care worker immunization as a criterion for accreditation of health care facilities throughout the nation.”

Otherwise, he envisions a beefed-up adult immunization infrastructure as being a copy of that used for children. “We would see health care providers being proactive and providing immunization services to their patients just as pediatricians now do for children. Currently in the United States, public money purchases vaccines for about half of children. … There's little that can come close in terms of adult immunization.”

Adult education also is neglected, according to Dr. Neumann. “One of my favorite ways of expressing that is that many of us in the baby boom generation think that we're immortal, and we do well for 20 or 30 years and, boom! We end up with chest pains, and we go see a cardiologist. Well, the cardiologist will take care of your cardiac issues, but the cardiologist isn't even thinking about influenza or pneumococcal immunization, even if you're in a high-risk group. So there's a lot of provider education that we need to do as well, through CME and other programs.”

Initiating a full starting dose of levothyroxine is safe for hypothyroid patients, and is more convenient and cost effective than working up from a lower dose, according to a prospective study.

Annemieke Roos, M.D., of the Medical Centre Rijnmond-Zuid in Rotterdam, the Netherlands, and colleagues, observed that “high doses of levothyroxine have been given to patients with myxedema coma, a patient group in whom a high prevalence of cardiac ischemia would be expected, without untoward effects,” except when levothyroxine is combined with T₃.

In their study, the investigators questioned what they called the “dogma of 'start low and go slow' irrespective of age or patient,” a concept they said was based on the association of hypothyroidism with ischemic heart disease (Arch. Intern. Med. 2005;165:1714–20).

Participants in the blinded study included 50 patients aged 22–86 years with first-diagnosed, untreated, primary autoimmune hypothyroidism. None of the patients had asymptomatic cardiac ischemia as demonstrated by dobutamine stress echocardiography or bicycle ergometry.

Study participants were randomized into two equal cohorts, and were started on either a high-dose regimen of oral levothyroxine (1.6 mcg/kg) or a low-dose (25 mcg) regimen that was initially adjusted with increments of 25 mcg every 4 weeks. Then, from 24 weeks onward, the dose was adjusted every 12 weeks according to serum thyrotropin and free thyroxine (FT₄) levels within the normal reference range (euthyroidism) as a target of treatment.

“At 4 weeks, median serum thyrotropin level[s] had normalized in the full-dose group… whereas in the low-dose group, the median thyrotropin level normalized only at 16 weeks,” the researchers said. “A similar significant difference between the full-dose and low-dose groups with regard to the normalization of the mean FT₄ and T₃ plasma levels was observed.”

There were no statistically significant differences in lipid or serum creatine kinase levels between the two groups.

“Starting healthy, adult patients aged 65 or older, or those older than 65 years with hypothyroidism but no history of ischemic heart disease, on a full dose of levothyroxine is supported by this study,” Dr. Roos and associates said. They noted that no cardiac events were observed in the study participants.

Dr. Roos and colleagues said that they believe their findings suggest that the prevalence of asymptomatic coronary artery disease in patients with untreated primary hypothyroidism is very low. They added that because patients with cardiac histories were excluded, “the findings … are possibly not applicable to patients with coronary artery disease.”

In an accompanying editorial, Leonard Wartofsky, M.D., of Washington Hospital Center, argued that there are still no compelling reasons to “go fast” (Arch. Intern. Med. 2005;165:1683–4).

“Myxedema coma still has a high mortality rate, and we cannot be certain whether a given patient's death might not have been due to aggressive levothyroxine therapy,” he said.

Dr. Wartofsky pointed out that the experimental protocol that Dr. Roos and colleagues used for the slow-titration group doesn't reflect what would be done in actual practice.

“Most cases of hypothyroidism are due to underlying Hashimoto disease, and a significant percentage of these patients have associated diabetes mellitus,” he said. “Given the high prevalence of coronary artery disease in patients with diabetes, I do not think that it is sufficient to rely on a history of 'no known ischemic heart disease' in such patients as validating the initiation of full-replacement dosage.”

Dr. Wartofsky also questioned the value of excluding patients with asymptomatic cardiac ischemia on the basis of dobutamine stress echocardiography.

Initiating a full starting dose of levothyroxine is safe for hypothyroid patients, and is more convenient and cost effective than working up from a lower dose, according to a prospective study.

Annemieke Roos, M.D., of the Medical Centre Rijnmond-Zuid in Rotterdam, the Netherlands, and colleagues, observed that “high doses of levothyroxine have been given to patients with myxedema coma, a patient group in whom a high prevalence of cardiac ischemia would be expected, without untoward effects,” except when levothyroxine is combined with T₃.

In their study, the investigators questioned what they called the “dogma of 'start low and go slow' irrespective of age or patient,” a concept they said was based on the association of hypothyroidism with ischemic heart disease (Arch. Intern. Med. 2005;165:1714–20).

Participants in the blinded study included 50 patients aged 22–86 years with first-diagnosed, untreated, primary autoimmune hypothyroidism. None of the patients had asymptomatic cardiac ischemia as demonstrated by dobutamine stress echocardiography or bicycle ergometry.

Study participants were randomized into two equal cohorts, and were started on either a high-dose regimen of oral levothyroxine (1.6 mcg/kg) or a low-dose (25 mcg) regimen that was initially adjusted with increments of 25 mcg every 4 weeks. Then, from 24 weeks onward, the dose was adjusted every 12 weeks according to serum thyrotropin and free thyroxine (FT₄) levels within the normal reference range (euthyroidism) as a target of treatment.

“At 4 weeks, median serum thyrotropin level[s] had normalized in the full-dose group… whereas in the low-dose group, the median thyrotropin level normalized only at 16 weeks,” the researchers said. “A similar significant difference between the full-dose and low-dose groups with regard to the normalization of the mean FT₄ and T₃ plasma levels was observed.”

There were no statistically significant differences in lipid or serum creatine kinase levels between the two groups.

“Starting healthy, adult patients aged 65 or older, or those older than 65 years with hypothyroidism but no history of ischemic heart disease, on a full dose of levothyroxine is supported by this study,” Dr. Roos and associates said. They noted that no cardiac events were observed in the study participants.

Dr. Roos and colleagues said that they believe their findings suggest that the prevalence of asymptomatic coronary artery disease in patients with untreated primary hypothyroidism is very low. They added that because patients with cardiac histories were excluded, “the findings … are possibly not applicable to patients with coronary artery disease.”

In an accompanying editorial, Leonard Wartofsky, M.D., of Washington Hospital Center, argued that there are still no compelling reasons to “go fast” (Arch. Intern. Med. 2005;165:1683–4).

“Myxedema coma still has a high mortality rate, and we cannot be certain whether a given patient's death might not have been due to aggressive levothyroxine therapy,” he said.

Dr. Wartofsky pointed out that the experimental protocol that Dr. Roos and colleagues used for the slow-titration group doesn't reflect what would be done in actual practice.

“Most cases of hypothyroidism are due to underlying Hashimoto disease, and a significant percentage of these patients have associated diabetes mellitus,” he said. “Given the high prevalence of coronary artery disease in patients with diabetes, I do not think that it is sufficient to rely on a history of 'no known ischemic heart disease' in such patients as validating the initiation of full-replacement dosage.”

Dr. Wartofsky also questioned the value of excluding patients with asymptomatic cardiac ischemia on the basis of dobutamine stress echocardiography.

Initiating a full starting dose of levothyroxine is safe for hypothyroid patients, and is more convenient and cost effective than working up from a lower dose, according to a prospective study.

Annemieke Roos, M.D., of the Medical Centre Rijnmond-Zuid in Rotterdam, the Netherlands, and colleagues, observed that “high doses of levothyroxine have been given to patients with myxedema coma, a patient group in whom a high prevalence of cardiac ischemia would be expected, without untoward effects,” except when levothyroxine is combined with T₃.

In their study, the investigators questioned what they called the “dogma of 'start low and go slow' irrespective of age or patient,” a concept they said was based on the association of hypothyroidism with ischemic heart disease (Arch. Intern. Med. 2005;165:1714–20).

Participants in the blinded study included 50 patients aged 22–86 years with first-diagnosed, untreated, primary autoimmune hypothyroidism. None of the patients had asymptomatic cardiac ischemia as demonstrated by dobutamine stress echocardiography or bicycle ergometry.

Study participants were randomized into two equal cohorts, and were started on either a high-dose regimen of oral levothyroxine (1.6 mcg/kg) or a low-dose (25 mcg) regimen that was initially adjusted with increments of 25 mcg every 4 weeks. Then, from 24 weeks onward, the dose was adjusted every 12 weeks according to serum thyrotropin and free thyroxine (FT₄) levels within the normal reference range (euthyroidism) as a target of treatment.

“At 4 weeks, median serum thyrotropin level[s] had normalized in the full-dose group… whereas in the low-dose group, the median thyrotropin level normalized only at 16 weeks,” the researchers said. “A similar significant difference between the full-dose and low-dose groups with regard to the normalization of the mean FT₄ and T₃ plasma levels was observed.”

There were no statistically significant differences in lipid or serum creatine kinase levels between the two groups.

“Starting healthy, adult patients aged 65 or older, or those older than 65 years with hypothyroidism but no history of ischemic heart disease, on a full dose of levothyroxine is supported by this study,” Dr. Roos and associates said. They noted that no cardiac events were observed in the study participants.

Dr. Roos and colleagues said that they believe their findings suggest that the prevalence of asymptomatic coronary artery disease in patients with untreated primary hypothyroidism is very low. They added that because patients with cardiac histories were excluded, “the findings … are possibly not applicable to patients with coronary artery disease.”

In an accompanying editorial, Leonard Wartofsky, M.D., of Washington Hospital Center, argued that there are still no compelling reasons to “go fast” (Arch. Intern. Med. 2005;165:1683–4).

“Myxedema coma still has a high mortality rate, and we cannot be certain whether a given patient's death might not have been due to aggressive levothyroxine therapy,” he said.

Dr. Wartofsky pointed out that the experimental protocol that Dr. Roos and colleagues used for the slow-titration group doesn't reflect what would be done in actual practice.

“Most cases of hypothyroidism are due to underlying Hashimoto disease, and a significant percentage of these patients have associated diabetes mellitus,” he said. “Given the high prevalence of coronary artery disease in patients with diabetes, I do not think that it is sufficient to rely on a history of 'no known ischemic heart disease' in such patients as validating the initiation of full-replacement dosage.”

Dr. Wartofsky also questioned the value of excluding patients with asymptomatic cardiac ischemia on the basis of dobutamine stress echocardiography.

Rabies should be part of the differential diagnosis of any patient hospitalized with encephalitis of unknown etiology, and rabies should be considered in people who have been bitten by a dog, especially if the bite occurs in a country where canine rabies is enzootic, according to the Centers for Disease Control and Prevention in Atlanta.

CDC investigators stressed the importance of early diagnosis and treatment of rabies, and they further underscored the point by describing a case of rabies that occurred last year in Florida (MMWR 2005;54:767–9).

In February 2004, a 41-year-old man died after a 4-day hospitalization; it was 8 months after the man had been bitten by a dog in Haiti. From the time he was bitten to the onset of symptoms 8 months later, the man reportedly was in normal health and felt well, said Tammy Blankenship, M.D., of the Broward County Health Department in Ft. Lauderdale.

A diagnosis of rabies was considered on the day before his death, but no antemortem samples were obtained for testing. On postmortem, the medical examiner described cytoplasmic inclusions consistent with Negri bodies. Postmortem samples of fixed brain tissue were sent to the CDC, where laboratory testing consequently confirmed a diagnosis of rabies.

“The man arrived at the hospital emergency department with a 2-day history of dysphagia accompanied by hyperventilation and agitation when he attempted to swallow liquids. The problem had worsened by the time of admission; he was noted as 'almost phobic' to liquids. The patient reported having had a brief period of mild fever. He was able to swallow soft, solid food and did not complain of throat pain or discomfort,” the CDC reported.

On the day the man was admitted to hospital, a neurology consultant concluded that the dysphasia etiology was unknown and recommended infectious disease, gastrointestinal, and pulmonary consultations. On his third day of hospitalization, the patient had a consistent fever of 103° F, with an elevated white blood cell count of 14.5/μL.

An infectious disease consultant recommended a lumbar puncture and testing for viral illness, especially rabies. The patient's wife said that her husband had been bitten on the fingertip by a dog while he was visiting Haiti 8 months earlier. That the dog was still alive could not be confirmed.

On the fourth day of hospitalization, the patient experienced diplopia, became decreasingly responsive, went into cardiopulmonary arrest, and died.

“In the United States, mandatory vaccination and stray-dog control programs have virtually eliminated circulation of any canine rabies-virus variant among dogs. In comparison, occurrence of rabies in dogs remains a problem in Haiti and other developing countries,” the CDC said.

The agency suggested that travelers avoid contact with dogs and other animals, and recommended rabies preexposure prophylaxis for those planning to stay 30 or more days in remote areas without access to medical care.

Health care professionals should keep mind that tests for rabies are available at CDC and can be arranged through state health departments.

“With the recent report from Wisconsin of a survivor of clinical rabies, rapid diagnosis of rabies is even more critical to managing a patient's clinical course, despite a poor prognosis,” the CDC said.

“In addition to enabling consideration of novel interventions, advantages of early diagnosis include prompt implementation of … infection control measures, thereby limiting the number of persons exposed or potentially exposed who require postexposure prophylaxis.”

The CDC reported a total of 8 cases of rabies in 2004 (including 4 transplant-associated cases and 1 involving an immigrant), the highest number of human rabies cases reported since 10 were identified in 1956.

Rabies should be part of the differential diagnosis of any patient hospitalized with encephalitis of unknown etiology, and rabies should be considered in people who have been bitten by a dog, especially if the bite occurs in a country where canine rabies is enzootic, according to the Centers for Disease Control and Prevention in Atlanta.

CDC investigators stressed the importance of early diagnosis and treatment of rabies, and they further underscored the point by describing a case of rabies that occurred last year in Florida (MMWR 2005;54:767–9).

In February 2004, a 41-year-old man died after a 4-day hospitalization; it was 8 months after the man had been bitten by a dog in Haiti. From the time he was bitten to the onset of symptoms 8 months later, the man reportedly was in normal health and felt well, said Tammy Blankenship, M.D., of the Broward County Health Department in Ft. Lauderdale.

A diagnosis of rabies was considered on the day before his death, but no antemortem samples were obtained for testing. On postmortem, the medical examiner described cytoplasmic inclusions consistent with Negri bodies. Postmortem samples of fixed brain tissue were sent to the CDC, where laboratory testing consequently confirmed a diagnosis of rabies.

“The man arrived at the hospital emergency department with a 2-day history of dysphagia accompanied by hyperventilation and agitation when he attempted to swallow liquids. The problem had worsened by the time of admission; he was noted as 'almost phobic' to liquids. The patient reported having had a brief period of mild fever. He was able to swallow soft, solid food and did not complain of throat pain or discomfort,” the CDC reported.

On the day the man was admitted to hospital, a neurology consultant concluded that the dysphasia etiology was unknown and recommended infectious disease, gastrointestinal, and pulmonary consultations. On his third day of hospitalization, the patient had a consistent fever of 103° F, with an elevated white blood cell count of 14.5/μL.

An infectious disease consultant recommended a lumbar puncture and testing for viral illness, especially rabies. The patient's wife said that her husband had been bitten on the fingertip by a dog while he was visiting Haiti 8 months earlier. That the dog was still alive could not be confirmed.

On the fourth day of hospitalization, the patient experienced diplopia, became decreasingly responsive, went into cardiopulmonary arrest, and died.

“In the United States, mandatory vaccination and stray-dog control programs have virtually eliminated circulation of any canine rabies-virus variant among dogs. In comparison, occurrence of rabies in dogs remains a problem in Haiti and other developing countries,” the CDC said.

The agency suggested that travelers avoid contact with dogs and other animals, and recommended rabies preexposure prophylaxis for those planning to stay 30 or more days in remote areas without access to medical care.

Health care professionals should keep mind that tests for rabies are available at CDC and can be arranged through state health departments.

“With the recent report from Wisconsin of a survivor of clinical rabies, rapid diagnosis of rabies is even more critical to managing a patient's clinical course, despite a poor prognosis,” the CDC said.

“In addition to enabling consideration of novel interventions, advantages of early diagnosis include prompt implementation of … infection control measures, thereby limiting the number of persons exposed or potentially exposed who require postexposure prophylaxis.”

The CDC reported a total of 8 cases of rabies in 2004 (including 4 transplant-associated cases and 1 involving an immigrant), the highest number of human rabies cases reported since 10 were identified in 1956.

Rabies should be part of the differential diagnosis of any patient hospitalized with encephalitis of unknown etiology, and rabies should be considered in people who have been bitten by a dog, especially if the bite occurs in a country where canine rabies is enzootic, according to the Centers for Disease Control and Prevention in Atlanta.

CDC investigators stressed the importance of early diagnosis and treatment of rabies, and they further underscored the point by describing a case of rabies that occurred last year in Florida (MMWR 2005;54:767–9).

In February 2004, a 41-year-old man died after a 4-day hospitalization; it was 8 months after the man had been bitten by a dog in Haiti. From the time he was bitten to the onset of symptoms 8 months later, the man reportedly was in normal health and felt well, said Tammy Blankenship, M.D., of the Broward County Health Department in Ft. Lauderdale.

A diagnosis of rabies was considered on the day before his death, but no antemortem samples were obtained for testing. On postmortem, the medical examiner described cytoplasmic inclusions consistent with Negri bodies. Postmortem samples of fixed brain tissue were sent to the CDC, where laboratory testing consequently confirmed a diagnosis of rabies.

“The man arrived at the hospital emergency department with a 2-day history of dysphagia accompanied by hyperventilation and agitation when he attempted to swallow liquids. The problem had worsened by the time of admission; he was noted as 'almost phobic' to liquids. The patient reported having had a brief period of mild fever. He was able to swallow soft, solid food and did not complain of throat pain or discomfort,” the CDC reported.

On the day the man was admitted to hospital, a neurology consultant concluded that the dysphasia etiology was unknown and recommended infectious disease, gastrointestinal, and pulmonary consultations. On his third day of hospitalization, the patient had a consistent fever of 103° F, with an elevated white blood cell count of 14.5/μL.

An infectious disease consultant recommended a lumbar puncture and testing for viral illness, especially rabies. The patient's wife said that her husband had been bitten on the fingertip by a dog while he was visiting Haiti 8 months earlier. That the dog was still alive could not be confirmed.

On the fourth day of hospitalization, the patient experienced diplopia, became decreasingly responsive, went into cardiopulmonary arrest, and died.

“In the United States, mandatory vaccination and stray-dog control programs have virtually eliminated circulation of any canine rabies-virus variant among dogs. In comparison, occurrence of rabies in dogs remains a problem in Haiti and other developing countries,” the CDC said.

The agency suggested that travelers avoid contact with dogs and other animals, and recommended rabies preexposure prophylaxis for those planning to stay 30 or more days in remote areas without access to medical care.

Health care professionals should keep mind that tests for rabies are available at CDC and can be arranged through state health departments.

“With the recent report from Wisconsin of a survivor of clinical rabies, rapid diagnosis of rabies is even more critical to managing a patient's clinical course, despite a poor prognosis,” the CDC said.

“In addition to enabling consideration of novel interventions, advantages of early diagnosis include prompt implementation of … infection control measures, thereby limiting the number of persons exposed or potentially exposed who require postexposure prophylaxis.”

The CDC reported a total of 8 cases of rabies in 2004 (including 4 transplant-associated cases and 1 involving an immigrant), the highest number of human rabies cases reported since 10 were identified in 1956.