Miriam E. Tucker

WASHINGTON — Whether or not a child receives at least three doses of pneumococcal conjugate vaccine depends upon the vaccine financing policy of the state he or she resides in, Shannon Stokley and her associates reported in a poster at the National Immunization Conference sponsored by the Centers for Disease Control and Prevention.

All states receive federal funds to purchase vaccine for children eligible for the Vaccines for Children (VFC) program, which covers all routine childhood vaccines for children who are Medicaid eligible, uninsured, Native American or Alaska Native, and those who are underinsured and receive vaccine at a federally qualified health clinic, said Ms. Stokley, an epidemiologist with the national immunization branch of the Centers for Disease Control and Prevention, Atlanta.

States also have the ability to use other state and federal funds to purchase additional vaccine for children who aren't VFC eligible. But because PCV7 is so expensive, some states have specifically excluded it from that additional coverage, she explained.

Ms. Stokley said that data were analyzed from the 2001-2003 National Immunization Survey for children aged 19-35 months living in 34 states plus one city with the following vaccine financing policies:

▸ VFC only (Ala., Colo., Ind., Iowa, La., Miss., Neb., N.J., Ohio, Ore., Pa., Tenn., Wis.). Supplies only VFC vaccine to all VFC-enrolled providers. However, public health clinics may provide all vaccines to all children who present for immunization.

▸ VFC and underinsured (Ariz., Fla., Ga., Md., Mich., Minn., N.Y., S.C., San Antonio). Supplies all vaccines for VFC-eligible and underinsured children to all VFC-enrolled providers.

▸ VFC and underinsured-select (Ill.). Supplies all vaccines for VFC eligible and all vaccines except PCV7 for underinsured children to all VFC-enrolled providers.

▸ Universal (Ark., Idaho, Mass., Maine, N.H., N.M., R.I., Wash.). Supplies all vaccines to all providers.

▸ Universal-select (Conn., Nev., S.D., Vt.). Supplies all vaccines except PCV7 for children who are underinsured or fully insured, to all providers.

Overall, the proportion of children who received one or more doses of PCV7 increased from 37.3% in 2001 (the year after it was licensed) to 88.5% in 2003. The proportion receiving at least the first three doses (recommended at 2, 4, and 6 months of age) increased from 6.7% in 2001 to 69% in 2003.

The likelihood of receiving three or more doses of PCV7 for children living in universal purchase states was 1.73 times greater than for children living in universal-select states, while the odds of receiving three or more doses of PCV7 for children in the VFC and underinsured states (plus San Antonio) were 1.06 times higher than for children in the VFC and underinsured-select states, Ms. Stokley and her associates reported.

After adjustment for a variety of child and provider factors, children living in universal-select or VFC and underinsured states had significantly lower odds of receiving three or more doses of PCV7, compared with children living in VFC-only states.

WASHINGTON — Whether or not a child receives at least three doses of pneumococcal conjugate vaccine depends upon the vaccine financing policy of the state he or she resides in, Shannon Stokley and her associates reported in a poster at the National Immunization Conference sponsored by the Centers for Disease Control and Prevention.

All states receive federal funds to purchase vaccine for children eligible for the Vaccines for Children (VFC) program, which covers all routine childhood vaccines for children who are Medicaid eligible, uninsured, Native American or Alaska Native, and those who are underinsured and receive vaccine at a federally qualified health clinic, said Ms. Stokley, an epidemiologist with the national immunization branch of the Centers for Disease Control and Prevention, Atlanta.

States also have the ability to use other state and federal funds to purchase additional vaccine for children who aren't VFC eligible. But because PCV7 is so expensive, some states have specifically excluded it from that additional coverage, she explained.

Ms. Stokley said that data were analyzed from the 2001-2003 National Immunization Survey for children aged 19-35 months living in 34 states plus one city with the following vaccine financing policies:

▸ VFC only (Ala., Colo., Ind., Iowa, La., Miss., Neb., N.J., Ohio, Ore., Pa., Tenn., Wis.). Supplies only VFC vaccine to all VFC-enrolled providers. However, public health clinics may provide all vaccines to all children who present for immunization.

▸ VFC and underinsured (Ariz., Fla., Ga., Md., Mich., Minn., N.Y., S.C., San Antonio). Supplies all vaccines for VFC-eligible and underinsured children to all VFC-enrolled providers.

▸ VFC and underinsured-select (Ill.). Supplies all vaccines for VFC eligible and all vaccines except PCV7 for underinsured children to all VFC-enrolled providers.

▸ Universal (Ark., Idaho, Mass., Maine, N.H., N.M., R.I., Wash.). Supplies all vaccines to all providers.

▸ Universal-select (Conn., Nev., S.D., Vt.). Supplies all vaccines except PCV7 for children who are underinsured or fully insured, to all providers.

Overall, the proportion of children who received one or more doses of PCV7 increased from 37.3% in 2001 (the year after it was licensed) to 88.5% in 2003. The proportion receiving at least the first three doses (recommended at 2, 4, and 6 months of age) increased from 6.7% in 2001 to 69% in 2003.

The likelihood of receiving three or more doses of PCV7 for children living in universal purchase states was 1.73 times greater than for children living in universal-select states, while the odds of receiving three or more doses of PCV7 for children in the VFC and underinsured states (plus San Antonio) were 1.06 times higher than for children in the VFC and underinsured-select states, Ms. Stokley and her associates reported.

After adjustment for a variety of child and provider factors, children living in universal-select or VFC and underinsured states had significantly lower odds of receiving three or more doses of PCV7, compared with children living in VFC-only states.

WASHINGTON — Whether or not a child receives at least three doses of pneumococcal conjugate vaccine depends upon the vaccine financing policy of the state he or she resides in, Shannon Stokley and her associates reported in a poster at the National Immunization Conference sponsored by the Centers for Disease Control and Prevention.

All states receive federal funds to purchase vaccine for children eligible for the Vaccines for Children (VFC) program, which covers all routine childhood vaccines for children who are Medicaid eligible, uninsured, Native American or Alaska Native, and those who are underinsured and receive vaccine at a federally qualified health clinic, said Ms. Stokley, an epidemiologist with the national immunization branch of the Centers for Disease Control and Prevention, Atlanta.

States also have the ability to use other state and federal funds to purchase additional vaccine for children who aren't VFC eligible. But because PCV7 is so expensive, some states have specifically excluded it from that additional coverage, she explained.

Ms. Stokley said that data were analyzed from the 2001-2003 National Immunization Survey for children aged 19-35 months living in 34 states plus one city with the following vaccine financing policies:

▸ VFC only (Ala., Colo., Ind., Iowa, La., Miss., Neb., N.J., Ohio, Ore., Pa., Tenn., Wis.). Supplies only VFC vaccine to all VFC-enrolled providers. However, public health clinics may provide all vaccines to all children who present for immunization.

▸ VFC and underinsured (Ariz., Fla., Ga., Md., Mich., Minn., N.Y., S.C., San Antonio). Supplies all vaccines for VFC-eligible and underinsured children to all VFC-enrolled providers.

▸ VFC and underinsured-select (Ill.). Supplies all vaccines for VFC eligible and all vaccines except PCV7 for underinsured children to all VFC-enrolled providers.

▸ Universal (Ark., Idaho, Mass., Maine, N.H., N.M., R.I., Wash.). Supplies all vaccines to all providers.

▸ Universal-select (Conn., Nev., S.D., Vt.). Supplies all vaccines except PCV7 for children who are underinsured or fully insured, to all providers.

Overall, the proportion of children who received one or more doses of PCV7 increased from 37.3% in 2001 (the year after it was licensed) to 88.5% in 2003. The proportion receiving at least the first three doses (recommended at 2, 4, and 6 months of age) increased from 6.7% in 2001 to 69% in 2003.

The likelihood of receiving three or more doses of PCV7 for children living in universal purchase states was 1.73 times greater than for children living in universal-select states, while the odds of receiving three or more doses of PCV7 for children in the VFC and underinsured states (plus San Antonio) were 1.06 times higher than for children in the VFC and underinsured-select states, Ms. Stokley and her associates reported.

After adjustment for a variety of child and provider factors, children living in universal-select or VFC and underinsured states had significantly lower odds of receiving three or more doses of PCV7, compared with children living in VFC-only states.

WASHINGTON — Physicians inappropriately delayed giving the third and fourth doses of pneumococcal conjugate vaccine to high-risk children during the 2004 shortage, Stephen M. Tannenbaum, M.D., reported at the National Immunization Conference sponsored by the Centers for Disease Control and Prevention.

During last year's shortfall of 7-valent pneumococcal conjugate vaccine (marketed as Prevnar), the CDC issued two sets of interim guidelines to ensure optimal distribution of available vaccine. First, on Feb. 13, the CDC advised that routine administration of the fourth dose be temporarily suspended for healthy children (MMWR 2004;53:108-9). Then, as manufacturing problems continued, on March 5 the CDC issued another notice calling for suspension of both the third and fourth doses to healthy children (MMWR 2004;53:177-8).

In both documents, the CDC specified that both vaccine doses should be continued in children at high risk for pneumococcal disease, including those with sickle cell disease and other hemoglobinopathies, chronic cardiac or pulmonary disease, diabetes, and HIV or other immunosuppressive conditions.

However, a review of Southern California Kaiser Permanente's Immunization Tracking System—which contains more than 3 million current members plus previous members—revealed that physicians were withholding the doses equally among high- and low-risk children, said Dr. Tannenbaum, a staff pediatrician at Kaiser Permanente, Los Angeles.

The review covered all doses of pneumococcal conjugate vaccine (PCV) administered by 437 pediatricians and 706 family physicians to children younger than 17 months of age during January-December 2004. The study had a birth cohort design: For each month, 2,073-3,180 healthy children and 0-37 high-risk children turned 3, 5, 7, and 16 months of age. Among the 633 high-risk children, the most common ICD-9 diagnoses listed were congenital heart anomalies (77%), sickle cell anemia (5%), and pulmonary conditions (4.5%), he reported.

Coverage for the first dose—assessed at 3 months of age—remained consistently high for both groups throughout 2004, in the 90% -95% range for low-risk children, and close to 100% for high-risk children. Coverage rates dropped slightly for the second dose, measured at 5 months, but remained relatively high in both groups throughout the year.

Following the first CDC notice, coverage rates for dose 4—measured at 16 months of age—dropped slowly and similarly in both high- and low-risk groups. By May, receipt of the fourth dose was nearly identical in both groups, at 41% of high-risk and 45% of low-risk children. By the time the CDC reinstated dose 4 on Sept. 17, coverage was just 6% for the high-risk and 4% for low-risk children, said Dr. Tannenbaum, who conducted the study with Maureen S. Kolasa, R.N., of the CDC.

Physicians were quicker in withholding dose 3 when that recommendation came out. Overall coverage—measured at 7 months—dropped from 55% in March to just 15% in April. It continued to fall to a low of 7% in June before rising again after the CDC reinstated it on July 9.

Although dose 3 coverage was slightly greater for high-risk vs. low-risk children during the period of its deferral, at no time were the differences significant. In April, for example, only 19% of high-risk children received dose 3, compared with 15% of low-risk children. In May, while the proportion of low-risk children receiving dose 3 dropped to just 8%, it remained at only 19% among the high-risk children, Dr. Tannenbaum reported.

By December 2004, after resumption of all doses, coverage had still not returned to preshortage levels, at just 16% of low-risk and 25% of high-risk children for dose 4, and 68% and 69%, respectively, for dose 3.

WASHINGTON — Physicians inappropriately delayed giving the third and fourth doses of pneumococcal conjugate vaccine to high-risk children during the 2004 shortage, Stephen M. Tannenbaum, M.D., reported at the National Immunization Conference sponsored by the Centers for Disease Control and Prevention.

During last year's shortfall of 7-valent pneumococcal conjugate vaccine (marketed as Prevnar), the CDC issued two sets of interim guidelines to ensure optimal distribution of available vaccine. First, on Feb. 13, the CDC advised that routine administration of the fourth dose be temporarily suspended for healthy children (MMWR 2004;53:108-9). Then, as manufacturing problems continued, on March 5 the CDC issued another notice calling for suspension of both the third and fourth doses to healthy children (MMWR 2004;53:177-8).

In both documents, the CDC specified that both vaccine doses should be continued in children at high risk for pneumococcal disease, including those with sickle cell disease and other hemoglobinopathies, chronic cardiac or pulmonary disease, diabetes, and HIV or other immunosuppressive conditions.

However, a review of Southern California Kaiser Permanente's Immunization Tracking System—which contains more than 3 million current members plus previous members—revealed that physicians were withholding the doses equally among high- and low-risk children, said Dr. Tannenbaum, a staff pediatrician at Kaiser Permanente, Los Angeles.

The review covered all doses of pneumococcal conjugate vaccine (PCV) administered by 437 pediatricians and 706 family physicians to children younger than 17 months of age during January-December 2004. The study had a birth cohort design: For each month, 2,073-3,180 healthy children and 0-37 high-risk children turned 3, 5, 7, and 16 months of age. Among the 633 high-risk children, the most common ICD-9 diagnoses listed were congenital heart anomalies (77%), sickle cell anemia (5%), and pulmonary conditions (4.5%), he reported.

Coverage for the first dose—assessed at 3 months of age—remained consistently high for both groups throughout 2004, in the 90% -95% range for low-risk children, and close to 100% for high-risk children. Coverage rates dropped slightly for the second dose, measured at 5 months, but remained relatively high in both groups throughout the year.

Following the first CDC notice, coverage rates for dose 4—measured at 16 months of age—dropped slowly and similarly in both high- and low-risk groups. By May, receipt of the fourth dose was nearly identical in both groups, at 41% of high-risk and 45% of low-risk children. By the time the CDC reinstated dose 4 on Sept. 17, coverage was just 6% for the high-risk and 4% for low-risk children, said Dr. Tannenbaum, who conducted the study with Maureen S. Kolasa, R.N., of the CDC.

Physicians were quicker in withholding dose 3 when that recommendation came out. Overall coverage—measured at 7 months—dropped from 55% in March to just 15% in April. It continued to fall to a low of 7% in June before rising again after the CDC reinstated it on July 9.

Although dose 3 coverage was slightly greater for high-risk vs. low-risk children during the period of its deferral, at no time were the differences significant. In April, for example, only 19% of high-risk children received dose 3, compared with 15% of low-risk children. In May, while the proportion of low-risk children receiving dose 3 dropped to just 8%, it remained at only 19% among the high-risk children, Dr. Tannenbaum reported.

By December 2004, after resumption of all doses, coverage had still not returned to preshortage levels, at just 16% of low-risk and 25% of high-risk children for dose 4, and 68% and 69%, respectively, for dose 3.

WASHINGTON — Physicians inappropriately delayed giving the third and fourth doses of pneumococcal conjugate vaccine to high-risk children during the 2004 shortage, Stephen M. Tannenbaum, M.D., reported at the National Immunization Conference sponsored by the Centers for Disease Control and Prevention.

During last year's shortfall of 7-valent pneumococcal conjugate vaccine (marketed as Prevnar), the CDC issued two sets of interim guidelines to ensure optimal distribution of available vaccine. First, on Feb. 13, the CDC advised that routine administration of the fourth dose be temporarily suspended for healthy children (MMWR 2004;53:108-9). Then, as manufacturing problems continued, on March 5 the CDC issued another notice calling for suspension of both the third and fourth doses to healthy children (MMWR 2004;53:177-8).

In both documents, the CDC specified that both vaccine doses should be continued in children at high risk for pneumococcal disease, including those with sickle cell disease and other hemoglobinopathies, chronic cardiac or pulmonary disease, diabetes, and HIV or other immunosuppressive conditions.

However, a review of Southern California Kaiser Permanente's Immunization Tracking System—which contains more than 3 million current members plus previous members—revealed that physicians were withholding the doses equally among high- and low-risk children, said Dr. Tannenbaum, a staff pediatrician at Kaiser Permanente, Los Angeles.

The review covered all doses of pneumococcal conjugate vaccine (PCV) administered by 437 pediatricians and 706 family physicians to children younger than 17 months of age during January-December 2004. The study had a birth cohort design: For each month, 2,073-3,180 healthy children and 0-37 high-risk children turned 3, 5, 7, and 16 months of age. Among the 633 high-risk children, the most common ICD-9 diagnoses listed were congenital heart anomalies (77%), sickle cell anemia (5%), and pulmonary conditions (4.5%), he reported.

Coverage for the first dose—assessed at 3 months of age—remained consistently high for both groups throughout 2004, in the 90% -95% range for low-risk children, and close to 100% for high-risk children. Coverage rates dropped slightly for the second dose, measured at 5 months, but remained relatively high in both groups throughout the year.

Following the first CDC notice, coverage rates for dose 4—measured at 16 months of age—dropped slowly and similarly in both high- and low-risk groups. By May, receipt of the fourth dose was nearly identical in both groups, at 41% of high-risk and 45% of low-risk children. By the time the CDC reinstated dose 4 on Sept. 17, coverage was just 6% for the high-risk and 4% for low-risk children, said Dr. Tannenbaum, who conducted the study with Maureen S. Kolasa, R.N., of the CDC.

Physicians were quicker in withholding dose 3 when that recommendation came out. Overall coverage—measured at 7 months—dropped from 55% in March to just 15% in April. It continued to fall to a low of 7% in June before rising again after the CDC reinstated it on July 9.

Although dose 3 coverage was slightly greater for high-risk vs. low-risk children during the period of its deferral, at no time were the differences significant. In April, for example, only 19% of high-risk children received dose 3, compared with 15% of low-risk children. In May, while the proportion of low-risk children receiving dose 3 dropped to just 8%, it remained at only 19% among the high-risk children, Dr. Tannenbaum reported.

By December 2004, after resumption of all doses, coverage had still not returned to preshortage levels, at just 16% of low-risk and 25% of high-risk children for dose 4, and 68% and 69%, respectively, for dose 3.

Varicella is still around despite the vaccine—and in some cases it can still be fatal, according to the Centers for Disease Control and Prevention.

Varicella vaccination is more than 95% effective against severe disease, and, since 1996, has been recommended for routine administration to children aged 12-18 months and to all susceptible persons aged 13 years and older. For children aged 19-35 months, national estimates of varicella vaccine coverage increased from 26% in 1997 to 85% in 2003, resulting in substantial reductions in varicella morbidity and mortality.

In two Varicella Active Surveillance Project sites—Antelope Valley, Calif., and West Philadelphia, Pa.—the number of reported cases dropped by approximately 85% during 1995-2003, and hospitalizations by about 70%. Yet, cases are still occurring among both vaccinated and unvaccinated individuals, as are a small number of varicella-related deaths among those not vaccinated or whose vaccination status is unknown, the CDC said in two separate reports (MMWR 2005;54:272-6).

During 2003 and the first half of 2004, the CDC received reports of eight varicella-related deaths, of whom six were unvaccinated and vaccine status unknown for the other two. The decedents ranged from 1 to 40 years, including six children and adolescents younger than 20 years of age. Three of the children had preexisting immunosuppressive conditions.

The other three, all initially healthy, were a 12-year-old boy, a 10-year-old girl, and a 14-month-old girl. None had been vaccinated or previously had the disease. Two had been exposed to classmates with varicella, while the source for the third child was unknown. All three had been brought to the emergency room with rashes consistent with varicella.

The 12-year-old was having repetitive episodes of vomiting, shortness of breath, and weakness. He was afebrile and initially had a 97% pulse oximetry, which dropped to 69% after he was hospitalized. He died on the second hospital day after having a seizure and becoming apneic. The 10-year-old died on the fourth hospital day after hospitalization for fever, ataxia, and changes in mental status.

The third child was admitted to the hospital with vomiting, diarrhea, fever, and reduced oral intake 3 days after her rash first appeared. She became hypotensive and was diagnosed with varicella and septic shock. Despite fluid resuscitation, intravenous ceftriaxone, vancomycin, and acetaminophen and transfer to a children's hospital, she developed respiratory and cardiac arrest and died less than an hour after arriving, the CDC reported.

To prevent varicella among children in the age range of the older two who died, middle- and high-school entry vaccination requirements will be necessary. By June 2004, a total of 44 states had implemented child care and/or school entry requirements for varicella vaccination. However, as of March 2005, only 18 states had included middle- or high-school entry requirements, the CDC said.

In Oregon, which has requirements for vaccination prior to out-of-home child care, kindergarten, and seventh grade, the Multnomah County school district has been conducting surveillance since the 2002-2003 school year for 37,850 students in 109 public elementary schools in kindergarten through fifth grade (5-10 years old).

Overall for the 2002-2003 and 2003-2004 school years, approximately 60% of varicella cases occurred as a single case in classrooms, while 40% were part of classroom outbreaks (defined as two or more cases within 21 days). Twenty-two percent were among students aged 7 years, while 19% occurred in 6-year-olds. Overall, 69% with varicella had been vaccinated, and 28% lacked evidence of immunity, having neither a history of vaccination nor of disease. Information was missing for the other 3%.

This school-based surveillance method detected more cases than physician-based surveillance alone would have.

Varicella is still around despite the vaccine—and in some cases it can still be fatal, according to the Centers for Disease Control and Prevention.

Varicella vaccination is more than 95% effective against severe disease, and, since 1996, has been recommended for routine administration to children aged 12-18 months and to all susceptible persons aged 13 years and older. For children aged 19-35 months, national estimates of varicella vaccine coverage increased from 26% in 1997 to 85% in 2003, resulting in substantial reductions in varicella morbidity and mortality.

In two Varicella Active Surveillance Project sites—Antelope Valley, Calif., and West Philadelphia, Pa.—the number of reported cases dropped by approximately 85% during 1995-2003, and hospitalizations by about 70%. Yet, cases are still occurring among both vaccinated and unvaccinated individuals, as are a small number of varicella-related deaths among those not vaccinated or whose vaccination status is unknown, the CDC said in two separate reports (MMWR 2005;54:272-6).

During 2003 and the first half of 2004, the CDC received reports of eight varicella-related deaths, of whom six were unvaccinated and vaccine status unknown for the other two. The decedents ranged from 1 to 40 years, including six children and adolescents younger than 20 years of age. Three of the children had preexisting immunosuppressive conditions.

The other three, all initially healthy, were a 12-year-old boy, a 10-year-old girl, and a 14-month-old girl. None had been vaccinated or previously had the disease. Two had been exposed to classmates with varicella, while the source for the third child was unknown. All three had been brought to the emergency room with rashes consistent with varicella.

The 12-year-old was having repetitive episodes of vomiting, shortness of breath, and weakness. He was afebrile and initially had a 97% pulse oximetry, which dropped to 69% after he was hospitalized. He died on the second hospital day after having a seizure and becoming apneic. The 10-year-old died on the fourth hospital day after hospitalization for fever, ataxia, and changes in mental status.

The third child was admitted to the hospital with vomiting, diarrhea, fever, and reduced oral intake 3 days after her rash first appeared. She became hypotensive and was diagnosed with varicella and septic shock. Despite fluid resuscitation, intravenous ceftriaxone, vancomycin, and acetaminophen and transfer to a children's hospital, she developed respiratory and cardiac arrest and died less than an hour after arriving, the CDC reported.

To prevent varicella among children in the age range of the older two who died, middle- and high-school entry vaccination requirements will be necessary. By June 2004, a total of 44 states had implemented child care and/or school entry requirements for varicella vaccination. However, as of March 2005, only 18 states had included middle- or high-school entry requirements, the CDC said.

In Oregon, which has requirements for vaccination prior to out-of-home child care, kindergarten, and seventh grade, the Multnomah County school district has been conducting surveillance since the 2002-2003 school year for 37,850 students in 109 public elementary schools in kindergarten through fifth grade (5-10 years old).

Overall for the 2002-2003 and 2003-2004 school years, approximately 60% of varicella cases occurred as a single case in classrooms, while 40% were part of classroom outbreaks (defined as two or more cases within 21 days). Twenty-two percent were among students aged 7 years, while 19% occurred in 6-year-olds. Overall, 69% with varicella had been vaccinated, and 28% lacked evidence of immunity, having neither a history of vaccination nor of disease. Information was missing for the other 3%.

This school-based surveillance method detected more cases than physician-based surveillance alone would have.

Varicella is still around despite the vaccine—and in some cases it can still be fatal, according to the Centers for Disease Control and Prevention.

Varicella vaccination is more than 95% effective against severe disease, and, since 1996, has been recommended for routine administration to children aged 12-18 months and to all susceptible persons aged 13 years and older. For children aged 19-35 months, national estimates of varicella vaccine coverage increased from 26% in 1997 to 85% in 2003, resulting in substantial reductions in varicella morbidity and mortality.

In two Varicella Active Surveillance Project sites—Antelope Valley, Calif., and West Philadelphia, Pa.—the number of reported cases dropped by approximately 85% during 1995-2003, and hospitalizations by about 70%. Yet, cases are still occurring among both vaccinated and unvaccinated individuals, as are a small number of varicella-related deaths among those not vaccinated or whose vaccination status is unknown, the CDC said in two separate reports (MMWR 2005;54:272-6).

During 2003 and the first half of 2004, the CDC received reports of eight varicella-related deaths, of whom six were unvaccinated and vaccine status unknown for the other two. The decedents ranged from 1 to 40 years, including six children and adolescents younger than 20 years of age. Three of the children had preexisting immunosuppressive conditions.

The other three, all initially healthy, were a 12-year-old boy, a 10-year-old girl, and a 14-month-old girl. None had been vaccinated or previously had the disease. Two had been exposed to classmates with varicella, while the source for the third child was unknown. All three had been brought to the emergency room with rashes consistent with varicella.

The 12-year-old was having repetitive episodes of vomiting, shortness of breath, and weakness. He was afebrile and initially had a 97% pulse oximetry, which dropped to 69% after he was hospitalized. He died on the second hospital day after having a seizure and becoming apneic. The 10-year-old died on the fourth hospital day after hospitalization for fever, ataxia, and changes in mental status.

The third child was admitted to the hospital with vomiting, diarrhea, fever, and reduced oral intake 3 days after her rash first appeared. She became hypotensive and was diagnosed with varicella and septic shock. Despite fluid resuscitation, intravenous ceftriaxone, vancomycin, and acetaminophen and transfer to a children's hospital, she developed respiratory and cardiac arrest and died less than an hour after arriving, the CDC reported.

To prevent varicella among children in the age range of the older two who died, middle- and high-school entry vaccination requirements will be necessary. By June 2004, a total of 44 states had implemented child care and/or school entry requirements for varicella vaccination. However, as of March 2005, only 18 states had included middle- or high-school entry requirements, the CDC said.

In Oregon, which has requirements for vaccination prior to out-of-home child care, kindergarten, and seventh grade, the Multnomah County school district has been conducting surveillance since the 2002-2003 school year for 37,850 students in 109 public elementary schools in kindergarten through fifth grade (5-10 years old).

Overall for the 2002-2003 and 2003-2004 school years, approximately 60% of varicella cases occurred as a single case in classrooms, while 40% were part of classroom outbreaks (defined as two or more cases within 21 days). Twenty-two percent were among students aged 7 years, while 19% occurred in 6-year-olds. Overall, 69% with varicella had been vaccinated, and 28% lacked evidence of immunity, having neither a history of vaccination nor of disease. Information was missing for the other 3%.

This school-based surveillance method detected more cases than physician-based surveillance alone would have.

NEW YORK — Interstitial cystitis frequently coexists with adenomyosis, just as it does with endometriosis, Stephen A. Grochmal, M.D., said at an international congress of the Society of Laparoendoscopic Surgeons.

“How many patients do we have who continue to have pain after endometrial ablation or after hysterectomy? Before we send them to a psychiatrist, perhaps we ought to give them a 5-minute screening questionnaire to see if they have associated interstitial cystitis,” Dr. Grochmal of the division of operative gynecology, endoscopy, and laser surgery at Howard University, Washington.

If the patient's score on that questionnaire—the Pelvic Pain and Urgency/Frequency (PUF) patient symptom scale—suggests interstitial cystitis (IC), then diagnostic tests are indicated.

In 2002, Maurice K. Chung, M.D., and associates described the “evil twins” of endometriosis and IC in chronic pelvic pain syndrome after finding a 70% overlap of the two conditions in 60 women (JSLS 2002;6:311-4).

“I considered that we might see the same thing with adenomyosis. After all, it is endometriosis of the myometrium,” Dr. Grochmal explained.

So he retrospectively analyzed 287 women who were part of an ongoing study that compared the long-term effect on amenorrhea rates of endometrial resection by Nd:YAG laser versus resectoscope. Despite alleviation of their uterine bleeding, 60% (172) reported postoperative chronic pelvic pain, along with urinary urgency and frequency, dysuria, rectal pain, perineal pain, dysmenorrhea, decreased sexual intimacy, and decreased quality of life.

Following a review of their surgical pathology reports and examination of uterine shavings or laser-excised tissue strips to exclude subbasalis diagnoses, “pure” adenomyosis was confirmed in 48 (28%) of the women. Of them, 32 (67%) had a score greater than 6 on the PUF scale, suggesting IC. Of those 32, 27 (84%) had positive potassium sensitivity test scores.

With use of established criteria for cystoscopy/hydrodistention, IC was confirmed in 25 (78%) of the 32 women, and in 1 (6%) of the 16 women with PUF scores less than 6.

Of the remaining 124 chronic pelvic pain patients who did not have adenomyosis, 54 were randomly selected for the same testing. Of those, 6 (11%) also had confirmed IC, in contrast to the total 60% of those with adenomyosis. In patients who have chronic pelvic pain after treatment for excessive uterine bleeding, adenomyosis may be the cause of the bleeding and the bladder may the cause of the chronic pelvic pain, Dr. Grochmal said.

NEW YORK — Interstitial cystitis frequently coexists with adenomyosis, just as it does with endometriosis, Stephen A. Grochmal, M.D., said at an international congress of the Society of Laparoendoscopic Surgeons.

“How many patients do we have who continue to have pain after endometrial ablation or after hysterectomy? Before we send them to a psychiatrist, perhaps we ought to give them a 5-minute screening questionnaire to see if they have associated interstitial cystitis,” Dr. Grochmal of the division of operative gynecology, endoscopy, and laser surgery at Howard University, Washington.

If the patient's score on that questionnaire—the Pelvic Pain and Urgency/Frequency (PUF) patient symptom scale—suggests interstitial cystitis (IC), then diagnostic tests are indicated.

In 2002, Maurice K. Chung, M.D., and associates described the “evil twins” of endometriosis and IC in chronic pelvic pain syndrome after finding a 70% overlap of the two conditions in 60 women (JSLS 2002;6:311-4).

“I considered that we might see the same thing with adenomyosis. After all, it is endometriosis of the myometrium,” Dr. Grochmal explained.

So he retrospectively analyzed 287 women who were part of an ongoing study that compared the long-term effect on amenorrhea rates of endometrial resection by Nd:YAG laser versus resectoscope. Despite alleviation of their uterine bleeding, 60% (172) reported postoperative chronic pelvic pain, along with urinary urgency and frequency, dysuria, rectal pain, perineal pain, dysmenorrhea, decreased sexual intimacy, and decreased quality of life.

Following a review of their surgical pathology reports and examination of uterine shavings or laser-excised tissue strips to exclude subbasalis diagnoses, “pure” adenomyosis was confirmed in 48 (28%) of the women. Of them, 32 (67%) had a score greater than 6 on the PUF scale, suggesting IC. Of those 32, 27 (84%) had positive potassium sensitivity test scores.

With use of established criteria for cystoscopy/hydrodistention, IC was confirmed in 25 (78%) of the 32 women, and in 1 (6%) of the 16 women with PUF scores less than 6.

Of the remaining 124 chronic pelvic pain patients who did not have adenomyosis, 54 were randomly selected for the same testing. Of those, 6 (11%) also had confirmed IC, in contrast to the total 60% of those with adenomyosis. In patients who have chronic pelvic pain after treatment for excessive uterine bleeding, adenomyosis may be the cause of the bleeding and the bladder may the cause of the chronic pelvic pain, Dr. Grochmal said.

NEW YORK — Interstitial cystitis frequently coexists with adenomyosis, just as it does with endometriosis, Stephen A. Grochmal, M.D., said at an international congress of the Society of Laparoendoscopic Surgeons.

“How many patients do we have who continue to have pain after endometrial ablation or after hysterectomy? Before we send them to a psychiatrist, perhaps we ought to give them a 5-minute screening questionnaire to see if they have associated interstitial cystitis,” Dr. Grochmal of the division of operative gynecology, endoscopy, and laser surgery at Howard University, Washington.

If the patient's score on that questionnaire—the Pelvic Pain and Urgency/Frequency (PUF) patient symptom scale—suggests interstitial cystitis (IC), then diagnostic tests are indicated.

In 2002, Maurice K. Chung, M.D., and associates described the “evil twins” of endometriosis and IC in chronic pelvic pain syndrome after finding a 70% overlap of the two conditions in 60 women (JSLS 2002;6:311-4).

“I considered that we might see the same thing with adenomyosis. After all, it is endometriosis of the myometrium,” Dr. Grochmal explained.

So he retrospectively analyzed 287 women who were part of an ongoing study that compared the long-term effect on amenorrhea rates of endometrial resection by Nd:YAG laser versus resectoscope. Despite alleviation of their uterine bleeding, 60% (172) reported postoperative chronic pelvic pain, along with urinary urgency and frequency, dysuria, rectal pain, perineal pain, dysmenorrhea, decreased sexual intimacy, and decreased quality of life.

Following a review of their surgical pathology reports and examination of uterine shavings or laser-excised tissue strips to exclude subbasalis diagnoses, “pure” adenomyosis was confirmed in 48 (28%) of the women. Of them, 32 (67%) had a score greater than 6 on the PUF scale, suggesting IC. Of those 32, 27 (84%) had positive potassium sensitivity test scores.

With use of established criteria for cystoscopy/hydrodistention, IC was confirmed in 25 (78%) of the 32 women, and in 1 (6%) of the 16 women with PUF scores less than 6.

Of the remaining 124 chronic pelvic pain patients who did not have adenomyosis, 54 were randomly selected for the same testing. Of those, 6 (11%) also had confirmed IC, in contrast to the total 60% of those with adenomyosis. In patients who have chronic pelvic pain after treatment for excessive uterine bleeding, adenomyosis may be the cause of the bleeding and the bladder may the cause of the chronic pelvic pain, Dr. Grochmal said.

VANCOUVER, B.C. — Emerging data all point in the same direction: The intensive lifestyle modification program developed by Dean Ornish, M.D., reduces cardiovascular risk, including that of patients with diabetes.

The Ornish program—consisting of a low-fat vegetarian diet, stress management, moderate exercise, smoking cessation, psychological group support, and encouragement of partner participation—has been shown to bring about regression of even severe coronary atherosclerosis (Lancet 1990;336:129-33).

Since 1998, the Ornish program has been studied in the ongoing Multisite Cardiac Lifestyle Intervention Program (MCLIP), which now includes more than 1,600 participants in more than 22 U.S. sites.

An earlier demonstration project involving 440 subjects in eight U.S. sites showed that women benefit as much as men (Am. J. Cardiol. 2003;91:1316-22); data from 250 of those subjects showed that the program works just as well in places like West Virginia and Nebraska as it does in California. Dr. Ornish presented the findings at the annual meeting of the American Heart Association (FAMILY PRACTICE NEWS, Jan. 1, 2004, p. 20).

Now, new MCLIP findings by three of Dr. Ornish's associates at the Preventive Medicine Research Institute (PMRI), Sausalito, Calif., suggest that the regimen—officially called The Dr. Dean Ornish Program for Reversing Heart Disease—works in diabetic patients with coronary heart disease, and that each of the program's individual components appears to play a significant role in overall benefit. The data were presented in posters at the annual meeting of the American Psychosomatic Society.

Adherence Helps Diabetic Patients

Michael D. Sumner, Ph.D., was the lead author of the diabetes study, which included 461 patients, of whom 10% had type 1 diabetes, 48% had diagnosed coronary heart disease (the rest had other risk factors), and 56% were female.

The patients achieved good adherence to the intervention: a plant-based diet with just 10% of calories from fat, at least 3 hours of moderate exercise per week, 7 hours per week of yoga and other stress-management techniques, and twice-weekly professionally supervised group support sessions. Mean dietary fat levels dropped from almost 30% of total calories to just 10%, weekly exercise levels increased from 1.3 to 3.8 hours, and weekly stress management practices rose from 0.4 to 6.3 hours. Mean support group attendance was 94%.

After 12 weeks, the group lost an average of 5.6 kg, and dropped from an average body mass index of 35.6 kg/m

The drop in triglycerides was significant only in the men, but the changes in all other variables were significant for both genders, Dr. Sumner and his associates noted.

Diabetes-related changes included a drop in hemoglobin A_1c from a mean of 7.5% to 6.7% and fasting glucose levels from 159 to 126 mg/dL, with similar results for both type 1 and type 2 diabetic patients. More than a third (39%) were able to reduce their use of diabetic medications. Quality of life measures, such as physical function, bodily pain, general health, vitality, and social functioning, also improved significantly, along with significant declines in measures of depression, hostility, and perceived stress.

Analyzing the Interventions

A second study, led by Jennifer Daubenmier, Ph.D., sought to determine the relative contributions of the program's individual behavior changes to reductions in coronary risk among 1,245 participants who had coronary heart disease (55%), diabetes, and/or at least three other risk factors (hypertension, hyperlipidemia, and obesity).

Changes at 12 weeks included significant reductions in weight (92.4 to 87.2 kg), functional capacity (9.0 to 10.9 metabolic equivalents), systolic blood pressure (133 to 123 mm Hg), diastolic blood pressure (79 to 73 mm Hg), total cholesterol (189 to 165 mg/dL), LDL cholesterol (108 to 92 mg/dL), and triglycerides (187 to 173 mg/dL). The group also had fewer depressive symptoms, lower hostility scores, and lower perceived stress after 12 weeks on the Ornish plan.

Regression analysis revealed significant additive effects of the health behaviors on decreases in weight, perceived stress, and depression at 12 weeks. For example, participants lost about 1.7% of body weight (1.53 kg) by reducing dietary fat, 1.2% (1.1 kg) through stress management practices, and 0.2% (0.18 kg) by exercising. (Remaining weight loss may have been due to other factors such as reduction in calories from sugar and alcohol.)

Reductions in dietary fat, exercise, and stress management also contributed significantly to levels of perceived stress, while improved diet and stress management contributed to lower depression scores.

The stress management component might indirectly boost the effects of diet and exercise in several ways. Yoga and meditation, for example, may facilitate healthier eating habits by increasing responsiveness to bodily cues and reducing stress-induced eating. Those practices might also mitigate cortisol-induced insulin resistance and weight gain.

“Traditional cardiac rehabilitation programs may increase their effectiveness by including a stress management component,” Dr. Daubenmier and her associates concluded.

Impact of Support Groups

The third analysis, from Ute Schulz, Ph.D., focused on the impact of the group support component among the 440 participants in the earlier eight-site demonstration project. At 1 year, significant changes in coronary risk factors included reductions in weight from 85 to 80 kg and in LDL/HDL ratio from 4 to 3, along with increases in physical and mental functioning.

On average, participants attended 77% of all offered support group sessions during the year. The more support group sessions participants attended, the more time they spent practicing stress management and exercising.

That, in turn, was associated with better physical and mental functioning, weight loss, and decreased LDL/HDL ratios.

“Support group attendance may indirectly influence changes in coronary risk factors by fostering participants' adherence to exercise and stress management.… These findings underline the importance of multicomponent programs in secondary prevention of CAD,” Dr. Schulz and her associates said.

Few in the medical community doubt the efficacy of the Ornish program—what they question is whether it can be implemented in the real world. Those who work at the PMRI—of which Dr. Ornish is founder, president, and director—hope that the final results from the MCLIP will encourage physicians to try harder to get patients into the program.

At a symposium held during the American Psychosomatic Society meeting, Gerdi Weidner, Ph.D., PMRI vice president and director of research, summarized the previously reported data on the Ornish program and offered this perspective when questioned about its real-world applicability: “Of course lifestyle changes are not for everyone, but open heart surgery's not for everyone, either. Once you've been stented three times, the fourth time is not for [anybody].”

VANCOUVER, B.C. — Emerging data all point in the same direction: The intensive lifestyle modification program developed by Dean Ornish, M.D., reduces cardiovascular risk, including that of patients with diabetes.

The Ornish program—consisting of a low-fat vegetarian diet, stress management, moderate exercise, smoking cessation, psychological group support, and encouragement of partner participation—has been shown to bring about regression of even severe coronary atherosclerosis (Lancet 1990;336:129-33).

Since 1998, the Ornish program has been studied in the ongoing Multisite Cardiac Lifestyle Intervention Program (MCLIP), which now includes more than 1,600 participants in more than 22 U.S. sites.

An earlier demonstration project involving 440 subjects in eight U.S. sites showed that women benefit as much as men (Am. J. Cardiol. 2003;91:1316-22); data from 250 of those subjects showed that the program works just as well in places like West Virginia and Nebraska as it does in California. Dr. Ornish presented the findings at the annual meeting of the American Heart Association (FAMILY PRACTICE NEWS, Jan. 1, 2004, p. 20).

Now, new MCLIP findings by three of Dr. Ornish's associates at the Preventive Medicine Research Institute (PMRI), Sausalito, Calif., suggest that the regimen—officially called The Dr. Dean Ornish Program for Reversing Heart Disease—works in diabetic patients with coronary heart disease, and that each of the program's individual components appears to play a significant role in overall benefit. The data were presented in posters at the annual meeting of the American Psychosomatic Society.

Adherence Helps Diabetic Patients

Michael D. Sumner, Ph.D., was the lead author of the diabetes study, which included 461 patients, of whom 10% had type 1 diabetes, 48% had diagnosed coronary heart disease (the rest had other risk factors), and 56% were female.

The patients achieved good adherence to the intervention: a plant-based diet with just 10% of calories from fat, at least 3 hours of moderate exercise per week, 7 hours per week of yoga and other stress-management techniques, and twice-weekly professionally supervised group support sessions. Mean dietary fat levels dropped from almost 30% of total calories to just 10%, weekly exercise levels increased from 1.3 to 3.8 hours, and weekly stress management practices rose from 0.4 to 6.3 hours. Mean support group attendance was 94%.

After 12 weeks, the group lost an average of 5.6 kg, and dropped from an average body mass index of 35.6 kg/m

The drop in triglycerides was significant only in the men, but the changes in all other variables were significant for both genders, Dr. Sumner and his associates noted.

Diabetes-related changes included a drop in hemoglobin A_1c from a mean of 7.5% to 6.7% and fasting glucose levels from 159 to 126 mg/dL, with similar results for both type 1 and type 2 diabetic patients. More than a third (39%) were able to reduce their use of diabetic medications. Quality of life measures, such as physical function, bodily pain, general health, vitality, and social functioning, also improved significantly, along with significant declines in measures of depression, hostility, and perceived stress.

Analyzing the Interventions

A second study, led by Jennifer Daubenmier, Ph.D., sought to determine the relative contributions of the program's individual behavior changes to reductions in coronary risk among 1,245 participants who had coronary heart disease (55%), diabetes, and/or at least three other risk factors (hypertension, hyperlipidemia, and obesity).

Changes at 12 weeks included significant reductions in weight (92.4 to 87.2 kg), functional capacity (9.0 to 10.9 metabolic equivalents), systolic blood pressure (133 to 123 mm Hg), diastolic blood pressure (79 to 73 mm Hg), total cholesterol (189 to 165 mg/dL), LDL cholesterol (108 to 92 mg/dL), and triglycerides (187 to 173 mg/dL). The group also had fewer depressive symptoms, lower hostility scores, and lower perceived stress after 12 weeks on the Ornish plan.

Regression analysis revealed significant additive effects of the health behaviors on decreases in weight, perceived stress, and depression at 12 weeks. For example, participants lost about 1.7% of body weight (1.53 kg) by reducing dietary fat, 1.2% (1.1 kg) through stress management practices, and 0.2% (0.18 kg) by exercising. (Remaining weight loss may have been due to other factors such as reduction in calories from sugar and alcohol.)

Reductions in dietary fat, exercise, and stress management also contributed significantly to levels of perceived stress, while improved diet and stress management contributed to lower depression scores.

The stress management component might indirectly boost the effects of diet and exercise in several ways. Yoga and meditation, for example, may facilitate healthier eating habits by increasing responsiveness to bodily cues and reducing stress-induced eating. Those practices might also mitigate cortisol-induced insulin resistance and weight gain.

“Traditional cardiac rehabilitation programs may increase their effectiveness by including a stress management component,” Dr. Daubenmier and her associates concluded.

Impact of Support Groups

The third analysis, from Ute Schulz, Ph.D., focused on the impact of the group support component among the 440 participants in the earlier eight-site demonstration project. At 1 year, significant changes in coronary risk factors included reductions in weight from 85 to 80 kg and in LDL/HDL ratio from 4 to 3, along with increases in physical and mental functioning.

On average, participants attended 77% of all offered support group sessions during the year. The more support group sessions participants attended, the more time they spent practicing stress management and exercising.

That, in turn, was associated with better physical and mental functioning, weight loss, and decreased LDL/HDL ratios.

“Support group attendance may indirectly influence changes in coronary risk factors by fostering participants' adherence to exercise and stress management.… These findings underline the importance of multicomponent programs in secondary prevention of CAD,” Dr. Schulz and her associates said.

Few in the medical community doubt the efficacy of the Ornish program—what they question is whether it can be implemented in the real world. Those who work at the PMRI—of which Dr. Ornish is founder, president, and director—hope that the final results from the MCLIP will encourage physicians to try harder to get patients into the program.

At a symposium held during the American Psychosomatic Society meeting, Gerdi Weidner, Ph.D., PMRI vice president and director of research, summarized the previously reported data on the Ornish program and offered this perspective when questioned about its real-world applicability: “Of course lifestyle changes are not for everyone, but open heart surgery's not for everyone, either. Once you've been stented three times, the fourth time is not for [anybody].”

VANCOUVER, B.C. — Emerging data all point in the same direction: The intensive lifestyle modification program developed by Dean Ornish, M.D., reduces cardiovascular risk, including that of patients with diabetes.

The Ornish program—consisting of a low-fat vegetarian diet, stress management, moderate exercise, smoking cessation, psychological group support, and encouragement of partner participation—has been shown to bring about regression of even severe coronary atherosclerosis (Lancet 1990;336:129-33).

Since 1998, the Ornish program has been studied in the ongoing Multisite Cardiac Lifestyle Intervention Program (MCLIP), which now includes more than 1,600 participants in more than 22 U.S. sites.

An earlier demonstration project involving 440 subjects in eight U.S. sites showed that women benefit as much as men (Am. J. Cardiol. 2003;91:1316-22); data from 250 of those subjects showed that the program works just as well in places like West Virginia and Nebraska as it does in California. Dr. Ornish presented the findings at the annual meeting of the American Heart Association (FAMILY PRACTICE NEWS, Jan. 1, 2004, p. 20).

Now, new MCLIP findings by three of Dr. Ornish's associates at the Preventive Medicine Research Institute (PMRI), Sausalito, Calif., suggest that the regimen—officially called The Dr. Dean Ornish Program for Reversing Heart Disease—works in diabetic patients with coronary heart disease, and that each of the program's individual components appears to play a significant role in overall benefit. The data were presented in posters at the annual meeting of the American Psychosomatic Society.

Adherence Helps Diabetic Patients

Michael D. Sumner, Ph.D., was the lead author of the diabetes study, which included 461 patients, of whom 10% had type 1 diabetes, 48% had diagnosed coronary heart disease (the rest had other risk factors), and 56% were female.

The patients achieved good adherence to the intervention: a plant-based diet with just 10% of calories from fat, at least 3 hours of moderate exercise per week, 7 hours per week of yoga and other stress-management techniques, and twice-weekly professionally supervised group support sessions. Mean dietary fat levels dropped from almost 30% of total calories to just 10%, weekly exercise levels increased from 1.3 to 3.8 hours, and weekly stress management practices rose from 0.4 to 6.3 hours. Mean support group attendance was 94%.

After 12 weeks, the group lost an average of 5.6 kg, and dropped from an average body mass index of 35.6 kg/m

The drop in triglycerides was significant only in the men, but the changes in all other variables were significant for both genders, Dr. Sumner and his associates noted.

Diabetes-related changes included a drop in hemoglobin A_1c from a mean of 7.5% to 6.7% and fasting glucose levels from 159 to 126 mg/dL, with similar results for both type 1 and type 2 diabetic patients. More than a third (39%) were able to reduce their use of diabetic medications. Quality of life measures, such as physical function, bodily pain, general health, vitality, and social functioning, also improved significantly, along with significant declines in measures of depression, hostility, and perceived stress.

Analyzing the Interventions

A second study, led by Jennifer Daubenmier, Ph.D., sought to determine the relative contributions of the program's individual behavior changes to reductions in coronary risk among 1,245 participants who had coronary heart disease (55%), diabetes, and/or at least three other risk factors (hypertension, hyperlipidemia, and obesity).

Changes at 12 weeks included significant reductions in weight (92.4 to 87.2 kg), functional capacity (9.0 to 10.9 metabolic equivalents), systolic blood pressure (133 to 123 mm Hg), diastolic blood pressure (79 to 73 mm Hg), total cholesterol (189 to 165 mg/dL), LDL cholesterol (108 to 92 mg/dL), and triglycerides (187 to 173 mg/dL). The group also had fewer depressive symptoms, lower hostility scores, and lower perceived stress after 12 weeks on the Ornish plan.

Regression analysis revealed significant additive effects of the health behaviors on decreases in weight, perceived stress, and depression at 12 weeks. For example, participants lost about 1.7% of body weight (1.53 kg) by reducing dietary fat, 1.2% (1.1 kg) through stress management practices, and 0.2% (0.18 kg) by exercising. (Remaining weight loss may have been due to other factors such as reduction in calories from sugar and alcohol.)

Reductions in dietary fat, exercise, and stress management also contributed significantly to levels of perceived stress, while improved diet and stress management contributed to lower depression scores.

The stress management component might indirectly boost the effects of diet and exercise in several ways. Yoga and meditation, for example, may facilitate healthier eating habits by increasing responsiveness to bodily cues and reducing stress-induced eating. Those practices might also mitigate cortisol-induced insulin resistance and weight gain.

“Traditional cardiac rehabilitation programs may increase their effectiveness by including a stress management component,” Dr. Daubenmier and her associates concluded.

Impact of Support Groups

The third analysis, from Ute Schulz, Ph.D., focused on the impact of the group support component among the 440 participants in the earlier eight-site demonstration project. At 1 year, significant changes in coronary risk factors included reductions in weight from 85 to 80 kg and in LDL/HDL ratio from 4 to 3, along with increases in physical and mental functioning.

On average, participants attended 77% of all offered support group sessions during the year. The more support group sessions participants attended, the more time they spent practicing stress management and exercising.

That, in turn, was associated with better physical and mental functioning, weight loss, and decreased LDL/HDL ratios.

“Support group attendance may indirectly influence changes in coronary risk factors by fostering participants' adherence to exercise and stress management.… These findings underline the importance of multicomponent programs in secondary prevention of CAD,” Dr. Schulz and her associates said.

Few in the medical community doubt the efficacy of the Ornish program—what they question is whether it can be implemented in the real world. Those who work at the PMRI—of which Dr. Ornish is founder, president, and director—hope that the final results from the MCLIP will encourage physicians to try harder to get patients into the program.

At a symposium held during the American Psychosomatic Society meeting, Gerdi Weidner, Ph.D., PMRI vice president and director of research, summarized the previously reported data on the Ornish program and offered this perspective when questioned about its real-world applicability: “Of course lifestyle changes are not for everyone, but open heart surgery's not for everyone, either. Once you've been stented three times, the fourth time is not for [anybody].”

VANCOUVER, B.C. – Yoga may be an effective adjunct to medical treatment for patients with fibromyalgia, Malinda L. Breda, Ph.D., reported at the annual meeting of the American Psychosomatic Society.

There are many reasons why yoga is an attractive treatment for fibromyalgia, which affects about 6 million Americans. Current therapies provide inadequate symptom relief, and a recent meta-analysis concluded that optimal treatment regimens should include nonpharmacologic interventions such as exercise (Ann Behav Med. 1999;21:180-91).

But although conventional exercise can alleviate symptoms for some fibromyalgia patients, it actually worsens them in others. Yoga, with its meditative, low-impact approach, may be better for these patients than conventional exercise. Moreover, data suggest that yoga may be beneficial in other medical conditions, including obsessive-compulsive disorder, osteoarthritis, carpal tunnel syndrome, chronic fatigue syndrome, and other pain conditions, noted Dr. Breda of the California School of Professional Psychology, San Diego.

Of 38 adults who met the 1990 American College of Rheumatology criteria for fibromyalgia, 19 were randomized to an experimental yoga group, and 19 controls were put on a waiting list.

The yoga intervention consisted of 8 weeks of classical hatha yoga, taught by a certified instructor who had experience with fibromyalgia patients, she said.

The 90-minute sessions emphasized gentle poses and breath work designed to match individual ability and were followed by relaxation/meditation exercises. Classes were conducted twice weekly, and subjects practiced at home with a video the other 5 days of each week. Class attendance was consistently high, with patients averaging 14 of 16 sessions. At-home practice adherence was slightly less impressive, with a mean of 3 of 5 days with yoga practice.

Instructor visual analog scale ratings, used to check manipulation, revealed significant improvement across sessions in patients' ability to perform the postures, Dr. Breda reported.

Patients completed a variety of assessments of pain, fatigue, sleep quality, and disability at baseline, 4 weeks, and 8 weeks.

Compared with controls, significant improvements were seen in the yoga group on the visual analog scale and the Pain Rating Index on ranked values, both for pain; the Multidimensional Assessment of Fatigue scale; the Pittsburgh Sleep Quality Index; and the Fibromyalgia Health Assessment Questionnaire.

The yoga group did not show significant improvements over time in disability, depression, or active coping scores. The control group showed no significant differences over time, except for worsening anxiety.

VANCOUVER, B.C. – Yoga may be an effective adjunct to medical treatment for patients with fibromyalgia, Malinda L. Breda, Ph.D., reported at the annual meeting of the American Psychosomatic Society.

There are many reasons why yoga is an attractive treatment for fibromyalgia, which affects about 6 million Americans. Current therapies provide inadequate symptom relief, and a recent meta-analysis concluded that optimal treatment regimens should include nonpharmacologic interventions such as exercise (Ann Behav Med. 1999;21:180-91).

But although conventional exercise can alleviate symptoms for some fibromyalgia patients, it actually worsens them in others. Yoga, with its meditative, low-impact approach, may be better for these patients than conventional exercise. Moreover, data suggest that yoga may be beneficial in other medical conditions, including obsessive-compulsive disorder, osteoarthritis, carpal tunnel syndrome, chronic fatigue syndrome, and other pain conditions, noted Dr. Breda of the California School of Professional Psychology, San Diego.

Of 38 adults who met the 1990 American College of Rheumatology criteria for fibromyalgia, 19 were randomized to an experimental yoga group, and 19 controls were put on a waiting list.

The yoga intervention consisted of 8 weeks of classical hatha yoga, taught by a certified instructor who had experience with fibromyalgia patients, she said.

The 90-minute sessions emphasized gentle poses and breath work designed to match individual ability and were followed by relaxation/meditation exercises. Classes were conducted twice weekly, and subjects practiced at home with a video the other 5 days of each week. Class attendance was consistently high, with patients averaging 14 of 16 sessions. At-home practice adherence was slightly less impressive, with a mean of 3 of 5 days with yoga practice.

Instructor visual analog scale ratings, used to check manipulation, revealed significant improvement across sessions in patients' ability to perform the postures, Dr. Breda reported.

Patients completed a variety of assessments of pain, fatigue, sleep quality, and disability at baseline, 4 weeks, and 8 weeks.

Compared with controls, significant improvements were seen in the yoga group on the visual analog scale and the Pain Rating Index on ranked values, both for pain; the Multidimensional Assessment of Fatigue scale; the Pittsburgh Sleep Quality Index; and the Fibromyalgia Health Assessment Questionnaire.

The yoga group did not show significant improvements over time in disability, depression, or active coping scores. The control group showed no significant differences over time, except for worsening anxiety.

VANCOUVER, B.C. – Yoga may be an effective adjunct to medical treatment for patients with fibromyalgia, Malinda L. Breda, Ph.D., reported at the annual meeting of the American Psychosomatic Society.

There are many reasons why yoga is an attractive treatment for fibromyalgia, which affects about 6 million Americans. Current therapies provide inadequate symptom relief, and a recent meta-analysis concluded that optimal treatment regimens should include nonpharmacologic interventions such as exercise (Ann Behav Med. 1999;21:180-91).

But although conventional exercise can alleviate symptoms for some fibromyalgia patients, it actually worsens them in others. Yoga, with its meditative, low-impact approach, may be better for these patients than conventional exercise. Moreover, data suggest that yoga may be beneficial in other medical conditions, including obsessive-compulsive disorder, osteoarthritis, carpal tunnel syndrome, chronic fatigue syndrome, and other pain conditions, noted Dr. Breda of the California School of Professional Psychology, San Diego.

Of 38 adults who met the 1990 American College of Rheumatology criteria for fibromyalgia, 19 were randomized to an experimental yoga group, and 19 controls were put on a waiting list.

The yoga intervention consisted of 8 weeks of classical hatha yoga, taught by a certified instructor who had experience with fibromyalgia patients, she said.

The 90-minute sessions emphasized gentle poses and breath work designed to match individual ability and were followed by relaxation/meditation exercises. Classes were conducted twice weekly, and subjects practiced at home with a video the other 5 days of each week. Class attendance was consistently high, with patients averaging 14 of 16 sessions. At-home practice adherence was slightly less impressive, with a mean of 3 of 5 days with yoga practice.

Instructor visual analog scale ratings, used to check manipulation, revealed significant improvement across sessions in patients' ability to perform the postures, Dr. Breda reported.

Patients completed a variety of assessments of pain, fatigue, sleep quality, and disability at baseline, 4 weeks, and 8 weeks.

Compared with controls, significant improvements were seen in the yoga group on the visual analog scale and the Pain Rating Index on ranked values, both for pain; the Multidimensional Assessment of Fatigue scale; the Pittsburgh Sleep Quality Index; and the Fibromyalgia Health Assessment Questionnaire.

The yoga group did not show significant improvements over time in disability, depression, or active coping scores. The control group showed no significant differences over time, except for worsening anxiety.

WASHINGTON — Using ancillary staff to obtain patient immunization and medication histories before the patient sees the physician could go a long way toward improving immunization rates among high-risk adults, Linda Hill, M.D., said at the National Immunization Conference sponsored by the Centers for Disease Control and Prevention.

Despite long-standing recommendations for annual influenza vaccine and one-time pneumococcal vaccination for adults aged 18-49 with chronic lung, cardiovascular, metabolic, and immunosuppressive conditions, overall coverage levels are only 20% for influenza vaccine and 8% for Pneumovax. Rates are just slightly better for diabetic patients, at 27% and 15%.

The Healthy People 2010 goal is 60% for both vaccines, said Dr. Hill of the department of preventive and family medicine at the University of California, San Diego.

In an effort to determine what types of preventive health issues are addressed during a typical office visit, Dr. Hill and her associates audiotaped 37 visits of patients ages 20-50 years with chronic conditions. Patients were seen at three community health centers and one private practice from September 2003 to January 2005.

The average visit lasted about 13 minutes. About 5 minutes were spent taking the patient's history, half a minute on providing generic health information, another 1-2 minutes on evaluations such as explaining test results, and about a half minute on the physical exam. Only fractions of minutes each were spent offering health recommendations, such as “you should get more exercise”; discussing preventive services other than immunizations, such as mammograms; and discussing and/or planning immunizations.

Of the 24 visits in which immunizations were discussed, the discussion took a little over a minute. But when immunizations were discussed and the patient actually got a shot, less than half a minute was spent on the discussion. And during those 24 visits, no other preventive health issues were discussed, noted Dr. Hill, who is also associate director of the Center for Behavioral Epidemiology and Community Health at San Diego State University.

Of interest, on average more than half of the visit (8 of the 13 minutes) was spent discussing the history, mostly the patient's medications. Although this isn't surprising, the actual discussion tended to be more about trying to figure out what the patient was taking and in what dose than about assessing the appropriateness of the dose or explaining to the patient what it was for.

Previous data have shown that, more than any patient characteristic, physician advice is the greatest predictor of receipt of immunizations. Moreover, physician immunization advice is more likely to occur when the physician to staff ratio is at least 1:4 and when the time spent with the physician is at least half of the visit time.

It would make sense to have ancillary staff members obtain and document immunization and medication histories prior to seeing the physician, thereby leaving the physician more time for more complex decisions and for talking with the patient about important preventive health measures such as immunization, Dr. Hill said.

WASHINGTON — Using ancillary staff to obtain patient immunization and medication histories before the patient sees the physician could go a long way toward improving immunization rates among high-risk adults, Linda Hill, M.D., said at the National Immunization Conference sponsored by the Centers for Disease Control and Prevention.

Despite long-standing recommendations for annual influenza vaccine and one-time pneumococcal vaccination for adults aged 18-49 with chronic lung, cardiovascular, metabolic, and immunosuppressive conditions, overall coverage levels are only 20% for influenza vaccine and 8% for Pneumovax. Rates are just slightly better for diabetic patients, at 27% and 15%.

The Healthy People 2010 goal is 60% for both vaccines, said Dr. Hill of the department of preventive and family medicine at the University of California, San Diego.

In an effort to determine what types of preventive health issues are addressed during a typical office visit, Dr. Hill and her associates audiotaped 37 visits of patients ages 20-50 years with chronic conditions. Patients were seen at three community health centers and one private practice from September 2003 to January 2005.

The average visit lasted about 13 minutes. About 5 minutes were spent taking the patient's history, half a minute on providing generic health information, another 1-2 minutes on evaluations such as explaining test results, and about a half minute on the physical exam. Only fractions of minutes each were spent offering health recommendations, such as “you should get more exercise”; discussing preventive services other than immunizations, such as mammograms; and discussing and/or planning immunizations.

Of the 24 visits in which immunizations were discussed, the discussion took a little over a minute. But when immunizations were discussed and the patient actually got a shot, less than half a minute was spent on the discussion. And during those 24 visits, no other preventive health issues were discussed, noted Dr. Hill, who is also associate director of the Center for Behavioral Epidemiology and Community Health at San Diego State University.

Of interest, on average more than half of the visit (8 of the 13 minutes) was spent discussing the history, mostly the patient's medications. Although this isn't surprising, the actual discussion tended to be more about trying to figure out what the patient was taking and in what dose than about assessing the appropriateness of the dose or explaining to the patient what it was for.

Previous data have shown that, more than any patient characteristic, physician advice is the greatest predictor of receipt of immunizations. Moreover, physician immunization advice is more likely to occur when the physician to staff ratio is at least 1:4 and when the time spent with the physician is at least half of the visit time.

It would make sense to have ancillary staff members obtain and document immunization and medication histories prior to seeing the physician, thereby leaving the physician more time for more complex decisions and for talking with the patient about important preventive health measures such as immunization, Dr. Hill said.

WASHINGTON — Using ancillary staff to obtain patient immunization and medication histories before the patient sees the physician could go a long way toward improving immunization rates among high-risk adults, Linda Hill, M.D., said at the National Immunization Conference sponsored by the Centers for Disease Control and Prevention.

Despite long-standing recommendations for annual influenza vaccine and one-time pneumococcal vaccination for adults aged 18-49 with chronic lung, cardiovascular, metabolic, and immunosuppressive conditions, overall coverage levels are only 20% for influenza vaccine and 8% for Pneumovax. Rates are just slightly better for diabetic patients, at 27% and 15%.

The Healthy People 2010 goal is 60% for both vaccines, said Dr. Hill of the department of preventive and family medicine at the University of California, San Diego.

In an effort to determine what types of preventive health issues are addressed during a typical office visit, Dr. Hill and her associates audiotaped 37 visits of patients ages 20-50 years with chronic conditions. Patients were seen at three community health centers and one private practice from September 2003 to January 2005.

The average visit lasted about 13 minutes. About 5 minutes were spent taking the patient's history, half a minute on providing generic health information, another 1-2 minutes on evaluations such as explaining test results, and about a half minute on the physical exam. Only fractions of minutes each were spent offering health recommendations, such as “you should get more exercise”; discussing preventive services other than immunizations, such as mammograms; and discussing and/or planning immunizations.

Of the 24 visits in which immunizations were discussed, the discussion took a little over a minute. But when immunizations were discussed and the patient actually got a shot, less than half a minute was spent on the discussion. And during those 24 visits, no other preventive health issues were discussed, noted Dr. Hill, who is also associate director of the Center for Behavioral Epidemiology and Community Health at San Diego State University.

Of interest, on average more than half of the visit (8 of the 13 minutes) was spent discussing the history, mostly the patient's medications. Although this isn't surprising, the actual discussion tended to be more about trying to figure out what the patient was taking and in what dose than about assessing the appropriateness of the dose or explaining to the patient what it was for.

Previous data have shown that, more than any patient characteristic, physician advice is the greatest predictor of receipt of immunizations. Moreover, physician immunization advice is more likely to occur when the physician to staff ratio is at least 1:4 and when the time spent with the physician is at least half of the visit time.

It would make sense to have ancillary staff members obtain and document immunization and medication histories prior to seeing the physician, thereby leaving the physician more time for more complex decisions and for talking with the patient about important preventive health measures such as immunization, Dr. Hill said.

Varicella is still around despite the vaccine—and in some cases it can still be fatal, according to the Centers for Disease Control and Prevention.

Varicella vaccination is more than 95% effective against severe disease and, since 1996, has been recommended for routine administration to 12- to 18-month-olds and to all susceptible persons aged 13 years and older. For children aged 19-35 months, national estimates of varicella vaccine coverage increased from 26% in 1997 to 85% in 2003, resulting in substantial reductions in varicella morbidity and mortality.

In two Varicella Active Surveillance Project sites—Antelope Valley, Calif., and West Philadelphia, Pa.—the number of reported cases fell about 85% during 1995-2003, and hospitalizations by about 70%. Yet, cases are still occurring among both vaccinated and unvaccinated individuals, as are a small number of varicella-related deaths among those not vaccinated or whose vaccination status is unknown, the CDC said in two reports (MMWR 2005;54:272-6).

During 2003 and the first half of 2004, the CDC received reports of eight varicella-related deaths—six were unvaccinated and vaccine status was unknown for two. The decedents ranged from 1 to 40 years, including six children and adolescents younger than 20 years. Three of the children had preexisting immunosuppressive conditions. The other three, all initially healthy, were a 12-year-old boy, a 10-year-old girl, and a 14-month-old girl. None had been vaccinated or previously had the disease. Two had been exposed to classmates with varicella, while the source for the third child was unknown. All three had been brought to the emergency room with rashes consistent with varicella.

The 12-year-old had episodes of vomiting, shortness of breath, and weakness. He was afebrile and initially had a 97% pulse oximetry, which dropped to 69% after hospitalization. He died on the second hospital day after having a seizure and apnea. The 10-year-old died on the fourth hospital day after hospitalization for fever, ataxia, and changes in mental status.

The third child was hospitalized with vomiting, diarrhea, fever, and reduced oral intake 3 days after her rash appeared. She became hypotensive and was diagnosed with varicella and septic shock. Despite fluid resuscitation, intravenous ceftriaxone, vancomycin, and acetaminophen and transfer to a children's hospital, she developed respiratory and cardiac arrest and died less than an hour after arriving, the CDC reported.

To prevent varicella in the age range of the older two who died, middle- and high-school entry vaccination requirements will be necessary. By June 2004, 44 states had implemented child care and/or school entry requirements for varicella vaccination. However, as of March 2005, only 18 states had included middle- or high-school entry requirements, the CDC said.

In Oregon, which has requirements for vaccination prior to out-of-home child care, kindergarten, and seventh grade, the Multnomah County school district has been conducting surveillance since the 2002-2003 school year for 37,850 students in 109 public elementary schools in kindergarten through fifth grade (5-10 years old).

For the 2002-2003 and 2003-2004 school years, about 60% of varicella cases occurred as a single case in classrooms, while 40% were part of classroom outbreaks (defined as two or more cases within 21 days). Twenty-two percent were in students aged 7 years, and 19% in 6-year-olds. Overall, 69% with varicella had been vaccinated, and 28% lacked evidence of immunity, having neither a history of vaccination nor of disease. Information was missing for 3%.

This school-based surveillance method detected more cases than physician-based surveillance would have. School nurses reported 90% of new varicella cases, with 88% subsequently confirmed by physicians, nurses, or parents. However, only 34% of the 2002-2003 cases and 44% of the 2003-2004 cases had been initially diagnosed by physicians, according to the CDC.

Varicella is still around despite the vaccine—and in some cases it can still be fatal, according to the Centers for Disease Control and Prevention.

Varicella vaccination is more than 95% effective against severe disease and, since 1996, has been recommended for routine administration to 12- to 18-month-olds and to all susceptible persons aged 13 years and older. For children aged 19-35 months, national estimates of varicella vaccine coverage increased from 26% in 1997 to 85% in 2003, resulting in substantial reductions in varicella morbidity and mortality.

In two Varicella Active Surveillance Project sites—Antelope Valley, Calif., and West Philadelphia, Pa.—the number of reported cases fell about 85% during 1995-2003, and hospitalizations by about 70%. Yet, cases are still occurring among both vaccinated and unvaccinated individuals, as are a small number of varicella-related deaths among those not vaccinated or whose vaccination status is unknown, the CDC said in two reports (MMWR 2005;54:272-6).

During 2003 and the first half of 2004, the CDC received reports of eight varicella-related deaths—six were unvaccinated and vaccine status was unknown for two. The decedents ranged from 1 to 40 years, including six children and adolescents younger than 20 years. Three of the children had preexisting immunosuppressive conditions. The other three, all initially healthy, were a 12-year-old boy, a 10-year-old girl, and a 14-month-old girl. None had been vaccinated or previously had the disease. Two had been exposed to classmates with varicella, while the source for the third child was unknown. All three had been brought to the emergency room with rashes consistent with varicella.

The 12-year-old had episodes of vomiting, shortness of breath, and weakness. He was afebrile and initially had a 97% pulse oximetry, which dropped to 69% after hospitalization. He died on the second hospital day after having a seizure and apnea. The 10-year-old died on the fourth hospital day after hospitalization for fever, ataxia, and changes in mental status.

The third child was hospitalized with vomiting, diarrhea, fever, and reduced oral intake 3 days after her rash appeared. She became hypotensive and was diagnosed with varicella and septic shock. Despite fluid resuscitation, intravenous ceftriaxone, vancomycin, and acetaminophen and transfer to a children's hospital, she developed respiratory and cardiac arrest and died less than an hour after arriving, the CDC reported.

To prevent varicella in the age range of the older two who died, middle- and high-school entry vaccination requirements will be necessary. By June 2004, 44 states had implemented child care and/or school entry requirements for varicella vaccination. However, as of March 2005, only 18 states had included middle- or high-school entry requirements, the CDC said.

In Oregon, which has requirements for vaccination prior to out-of-home child care, kindergarten, and seventh grade, the Multnomah County school district has been conducting surveillance since the 2002-2003 school year for 37,850 students in 109 public elementary schools in kindergarten through fifth grade (5-10 years old).

For the 2002-2003 and 2003-2004 school years, about 60% of varicella cases occurred as a single case in classrooms, while 40% were part of classroom outbreaks (defined as two or more cases within 21 days). Twenty-two percent were in students aged 7 years, and 19% in 6-year-olds. Overall, 69% with varicella had been vaccinated, and 28% lacked evidence of immunity, having neither a history of vaccination nor of disease. Information was missing for 3%.

This school-based surveillance method detected more cases than physician-based surveillance would have. School nurses reported 90% of new varicella cases, with 88% subsequently confirmed by physicians, nurses, or parents. However, only 34% of the 2002-2003 cases and 44% of the 2003-2004 cases had been initially diagnosed by physicians, according to the CDC.

Varicella is still around despite the vaccine—and in some cases it can still be fatal, according to the Centers for Disease Control and Prevention.

Varicella vaccination is more than 95% effective against severe disease and, since 1996, has been recommended for routine administration to 12- to 18-month-olds and to all susceptible persons aged 13 years and older. For children aged 19-35 months, national estimates of varicella vaccine coverage increased from 26% in 1997 to 85% in 2003, resulting in substantial reductions in varicella morbidity and mortality.

In two Varicella Active Surveillance Project sites—Antelope Valley, Calif., and West Philadelphia, Pa.—the number of reported cases fell about 85% during 1995-2003, and hospitalizations by about 70%. Yet, cases are still occurring among both vaccinated and unvaccinated individuals, as are a small number of varicella-related deaths among those not vaccinated or whose vaccination status is unknown, the CDC said in two reports (MMWR 2005;54:272-6).

During 2003 and the first half of 2004, the CDC received reports of eight varicella-related deaths—six were unvaccinated and vaccine status was unknown for two. The decedents ranged from 1 to 40 years, including six children and adolescents younger than 20 years. Three of the children had preexisting immunosuppressive conditions. The other three, all initially healthy, were a 12-year-old boy, a 10-year-old girl, and a 14-month-old girl. None had been vaccinated or previously had the disease. Two had been exposed to classmates with varicella, while the source for the third child was unknown. All three had been brought to the emergency room with rashes consistent with varicella.

The 12-year-old had episodes of vomiting, shortness of breath, and weakness. He was afebrile and initially had a 97% pulse oximetry, which dropped to 69% after hospitalization. He died on the second hospital day after having a seizure and apnea. The 10-year-old died on the fourth hospital day after hospitalization for fever, ataxia, and changes in mental status.

The third child was hospitalized with vomiting, diarrhea, fever, and reduced oral intake 3 days after her rash appeared. She became hypotensive and was diagnosed with varicella and septic shock. Despite fluid resuscitation, intravenous ceftriaxone, vancomycin, and acetaminophen and transfer to a children's hospital, she developed respiratory and cardiac arrest and died less than an hour after arriving, the CDC reported.

To prevent varicella in the age range of the older two who died, middle- and high-school entry vaccination requirements will be necessary. By June 2004, 44 states had implemented child care and/or school entry requirements for varicella vaccination. However, as of March 2005, only 18 states had included middle- or high-school entry requirements, the CDC said.

In Oregon, which has requirements for vaccination prior to out-of-home child care, kindergarten, and seventh grade, the Multnomah County school district has been conducting surveillance since the 2002-2003 school year for 37,850 students in 109 public elementary schools in kindergarten through fifth grade (5-10 years old).

For the 2002-2003 and 2003-2004 school years, about 60% of varicella cases occurred as a single case in classrooms, while 40% were part of classroom outbreaks (defined as two or more cases within 21 days). Twenty-two percent were in students aged 7 years, and 19% in 6-year-olds. Overall, 69% with varicella had been vaccinated, and 28% lacked evidence of immunity, having neither a history of vaccination nor of disease. Information was missing for 3%.

This school-based surveillance method detected more cases than physician-based surveillance would have. School nurses reported 90% of new varicella cases, with 88% subsequently confirmed by physicians, nurses, or parents. However, only 34% of the 2002-2003 cases and 44% of the 2003-2004 cases had been initially diagnosed by physicians, according to the CDC.

ATLANTA — Children and adults with neurologic and neuromuscular conditions that place them at increased risk for influenza complications will be added to the list of individuals who should be targeted to receive the vaccine, the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices decided at its winter meeting.

The final wording of the 2005-2006 influenza immunization statement is still being finalized, but in general, any neurologic and neuromuscular condition that increases the risk for respiratory compromise or aspiration would place patients at even greater risk if they were to contract influenza, said Carolyn Bridges, M.D., of the CDC's National Immunization Program.

The list of individual conditions is long, but it broadly includes seizure disorders, mental retardation, cerebral palsy, Down syndrome, muscular dystrophy, and other developmental problems with limitation. Among adults, stroke, multiple sclerosis, Parkinson's disease, and senility/dementia/Alzheimer's disease with limitation also are likely to be included.

Depending on which conditions are included in the final statement, the number of children and adults who may be added to the target list for influenza vaccination would be approximately 524,000-907,000 children aged 2-17 years, 529,000-1.7 million adults aged 18-49, and 571,000-844,000 individuals aged 50-64, Dr. Bridges said.

Among the data supporting the recommendation are preliminary findings from two studies in which such conditions were prevalent among children with severe influenza.

Of 153 fatal influenza cases reported during the 2003-2004 season in persons younger than 18 years (range 2 weeks to 17 years), 45% were previously healthy, 20% had conditions that ACIP had previously designated as high risk, while 20% had conditions such as congenital anomalies, gastrointestinal disorders, and neurologic/neuromuscular conditions. Another 20% had both neurologic/neuromuscular conditions and a previously designated high-risk condition. (No data were available for the other 3%.)

The neurologic conditions in those children were mental retardation/developmental delay, seizure disorder (excluding febrile), chronic encephalopathies, neurodegenerative disorders, and congenital neurologic disorders. The neuromuscular conditions were cerebral palsy and Duchenne's muscular dystrophy. Some children had more than one of the diagnoses.

A 4-year retrospective study of 757 children hospitalized with community-acquired, laboratory-confirmed influenza was conducted at Children's Hospital of Philadelphia, where diagnostic testing is routinely done for most children admitted with respiratory symptoms. Previously designated high-risk conditions were present in 44% of the children, the most common being asthma, in 24%, Dr. Bridges reported.

Among the 425 who did not have one of the previously listed conditions, neurologic/neuromuscular conditions were present in 22%. These included disease of the central or peripheral nervous system, seizure disorders, or myopathies. In a subanalysis of 33 children with respiratory failure, having a neurologic or neuromuscular condition increased the risk nearly sevenfold.

ATLANTA — Children and adults with neurologic and neuromuscular conditions that place them at increased risk for influenza complications will be added to the list of individuals who should be targeted to receive the vaccine, the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices decided at its winter meeting.

The final wording of the 2005-2006 influenza immunization statement is still being finalized, but in general, any neurologic and neuromuscular condition that increases the risk for respiratory compromise or aspiration would place patients at even greater risk if they were to contract influenza, said Carolyn Bridges, M.D., of the CDC's National Immunization Program.

The list of individual conditions is long, but it broadly includes seizure disorders, mental retardation, cerebral palsy, Down syndrome, muscular dystrophy, and other developmental problems with limitation. Among adults, stroke, multiple sclerosis, Parkinson's disease, and senility/dementia/Alzheimer's disease with limitation also are likely to be included.

Depending on which conditions are included in the final statement, the number of children and adults who may be added to the target list for influenza vaccination would be approximately 524,000-907,000 children aged 2-17 years, 529,000-1.7 million adults aged 18-49, and 571,000-844,000 individuals aged 50-64, Dr. Bridges said.

Among the data supporting the recommendation are preliminary findings from two studies in which such conditions were prevalent among children with severe influenza.

Of 153 fatal influenza cases reported during the 2003-2004 season in persons younger than 18 years (range 2 weeks to 17 years), 45% were previously healthy, 20% had conditions that ACIP had previously designated as high risk, while 20% had conditions such as congenital anomalies, gastrointestinal disorders, and neurologic/neuromuscular conditions. Another 20% had both neurologic/neuromuscular conditions and a previously designated high-risk condition. (No data were available for the other 3%.)

The neurologic conditions in those children were mental retardation/developmental delay, seizure disorder (excluding febrile), chronic encephalopathies, neurodegenerative disorders, and congenital neurologic disorders. The neuromuscular conditions were cerebral palsy and Duchenne's muscular dystrophy. Some children had more than one of the diagnoses.

A 4-year retrospective study of 757 children hospitalized with community-acquired, laboratory-confirmed influenza was conducted at Children's Hospital of Philadelphia, where diagnostic testing is routinely done for most children admitted with respiratory symptoms. Previously designated high-risk conditions were present in 44% of the children, the most common being asthma, in 24%, Dr. Bridges reported.

Among the 425 who did not have one of the previously listed conditions, neurologic/neuromuscular conditions were present in 22%. These included disease of the central or peripheral nervous system, seizure disorders, or myopathies. In a subanalysis of 33 children with respiratory failure, having a neurologic or neuromuscular condition increased the risk nearly sevenfold.

ATLANTA — Children and adults with neurologic and neuromuscular conditions that place them at increased risk for influenza complications will be added to the list of individuals who should be targeted to receive the vaccine, the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices decided at its winter meeting.

The final wording of the 2005-2006 influenza immunization statement is still being finalized, but in general, any neurologic and neuromuscular condition that increases the risk for respiratory compromise or aspiration would place patients at even greater risk if they were to contract influenza, said Carolyn Bridges, M.D., of the CDC's National Immunization Program.

The list of individual conditions is long, but it broadly includes seizure disorders, mental retardation, cerebral palsy, Down syndrome, muscular dystrophy, and other developmental problems with limitation. Among adults, stroke, multiple sclerosis, Parkinson's disease, and senility/dementia/Alzheimer's disease with limitation also are likely to be included.

Depending on which conditions are included in the final statement, the number of children and adults who may be added to the target list for influenza vaccination would be approximately 524,000-907,000 children aged 2-17 years, 529,000-1.7 million adults aged 18-49, and 571,000-844,000 individuals aged 50-64, Dr. Bridges said.

Among the data supporting the recommendation are preliminary findings from two studies in which such conditions were prevalent among children with severe influenza.

Of 153 fatal influenza cases reported during the 2003-2004 season in persons younger than 18 years (range 2 weeks to 17 years), 45% were previously healthy, 20% had conditions that ACIP had previously designated as high risk, while 20% had conditions such as congenital anomalies, gastrointestinal disorders, and neurologic/neuromuscular conditions. Another 20% had both neurologic/neuromuscular conditions and a previously designated high-risk condition. (No data were available for the other 3%.)

The neurologic conditions in those children were mental retardation/developmental delay, seizure disorder (excluding febrile), chronic encephalopathies, neurodegenerative disorders, and congenital neurologic disorders. The neuromuscular conditions were cerebral palsy and Duchenne's muscular dystrophy. Some children had more than one of the diagnoses.

A 4-year retrospective study of 757 children hospitalized with community-acquired, laboratory-confirmed influenza was conducted at Children's Hospital of Philadelphia, where diagnostic testing is routinely done for most children admitted with respiratory symptoms. Previously designated high-risk conditions were present in 44% of the children, the most common being asthma, in 24%, Dr. Bridges reported.

Among the 425 who did not have one of the previously listed conditions, neurologic/neuromuscular conditions were present in 22%. These included disease of the central or peripheral nervous system, seizure disorders, or myopathies. In a subanalysis of 33 children with respiratory failure, having a neurologic or neuromuscular condition increased the risk nearly sevenfold.

Always consider the possibility of bacterial contamination of blood products—particularly plate-lets—in patients who experience a febrile reaction to a transfusion, the Centers for Disease Control and Prevention advised.

Transfusion-associated bacterial sepsis is the second most frequently reported cause of transfusion-related mortality in the United States, accounting for 17% of 277 reported transfusion deaths during 1990-1998, the CDC said (MMWR 2005;54:168-70).

Platelets are particularly vulnerable to bacterial growth because they are stored at room temperature for up to 5 days, whereas other blood components are refrigerated or frozen. An estimated 1 in 1,000-3,000 platelet units are contaminated with bacteria, resulting in life-threatening sepsis in 1 of every 100,000 transfusion recipients and immediate death in 1 of every 500,000 recipients.

These risks are higher than those estimated for transfusion-associated viral infections such as hepatitis C virus or HIV—yet are still likely to be underestimated because bacterial infections attributed to contaminated platelets are underreported, the CDC said.

To reduce this risk, AABB (formerly the American Association of Blood Banks), adopted a new standard in March 2004 requiring member blood banks and transfusion services to implement measures to detect and limit bacterial contamination in all platelet components. Additional guidance for implementation of the standard—aimed at clinicians as well as institutions—was issued in February 2005. It is available at www.aabb.org

A survey conducted last summer by the Infectious Diseases Society of America (IDSA) suggested that awareness of the problem and of the new standard was not high.

The survey was distributed to all 870 infectious-disease consultant members of IDSA's Emerging Infections Network. Of the 399 who responded, only 36% reported being aware that bacterial contamination of platelets was one of the most common infection risks of transfusion therapy, and only 20% indicated having been familiar with the new AABB standard prior to participating in the survey. But, once informed, 90% believed that health care providers should be aware of the standard.

The CDC cited case reports that illustrated the need for awareness and rapid diagnosis of transfusion-associated infections, because false negatives—leading to fatal bacterial sepsis—can occur even when pretransfusion testing complies with the new standard.

In one case, a 74-year-old man with leukemia died of sepsis 21 days after receiving a pooled platelet transfusion. The pooled unit had been tested with a reagent strip to determine pH, a means of detecting bacteria. Even though the sample was in the accepted range, the patient's blood cultures following transfusion grew Staphylococcus aureus.

Although pH tests are an option under the AABB standard, they are less sensitive than culture-based methods. However, even culture-based testing can fail to detect bacterial contamination.

Always consider the possibility of bacterial contamination of blood products—particularly plate-lets—in patients who experience a febrile reaction to a transfusion, the Centers for Disease Control and Prevention advised.

Transfusion-associated bacterial sepsis is the second most frequently reported cause of transfusion-related mortality in the United States, accounting for 17% of 277 reported transfusion deaths during 1990-1998, the CDC said (MMWR 2005;54:168-70).

Platelets are particularly vulnerable to bacterial growth because they are stored at room temperature for up to 5 days, whereas other blood components are refrigerated or frozen. An estimated 1 in 1,000-3,000 platelet units are contaminated with bacteria, resulting in life-threatening sepsis in 1 of every 100,000 transfusion recipients and immediate death in 1 of every 500,000 recipients.

These risks are higher than those estimated for transfusion-associated viral infections such as hepatitis C virus or HIV—yet are still likely to be underestimated because bacterial infections attributed to contaminated platelets are underreported, the CDC said.

To reduce this risk, AABB (formerly the American Association of Blood Banks), adopted a new standard in March 2004 requiring member blood banks and transfusion services to implement measures to detect and limit bacterial contamination in all platelet components. Additional guidance for implementation of the standard—aimed at clinicians as well as institutions—was issued in February 2005. It is available at www.aabb.org

A survey conducted last summer by the Infectious Diseases Society of America (IDSA) suggested that awareness of the problem and of the new standard was not high.

The survey was distributed to all 870 infectious-disease consultant members of IDSA's Emerging Infections Network. Of the 399 who responded, only 36% reported being aware that bacterial contamination of platelets was one of the most common infection risks of transfusion therapy, and only 20% indicated having been familiar with the new AABB standard prior to participating in the survey. But, once informed, 90% believed that health care providers should be aware of the standard.

The CDC cited case reports that illustrated the need for awareness and rapid diagnosis of transfusion-associated infections, because false negatives—leading to fatal bacterial sepsis—can occur even when pretransfusion testing complies with the new standard.

In one case, a 74-year-old man with leukemia died of sepsis 21 days after receiving a pooled platelet transfusion. The pooled unit had been tested with a reagent strip to determine pH, a means of detecting bacteria. Even though the sample was in the accepted range, the patient's blood cultures following transfusion grew Staphylococcus aureus.

Although pH tests are an option under the AABB standard, they are less sensitive than culture-based methods. However, even culture-based testing can fail to detect bacterial contamination.

Always consider the possibility of bacterial contamination of blood products—particularly plate-lets—in patients who experience a febrile reaction to a transfusion, the Centers for Disease Control and Prevention advised.

Transfusion-associated bacterial sepsis is the second most frequently reported cause of transfusion-related mortality in the United States, accounting for 17% of 277 reported transfusion deaths during 1990-1998, the CDC said (MMWR 2005;54:168-70).

Platelets are particularly vulnerable to bacterial growth because they are stored at room temperature for up to 5 days, whereas other blood components are refrigerated or frozen. An estimated 1 in 1,000-3,000 platelet units are contaminated with bacteria, resulting in life-threatening sepsis in 1 of every 100,000 transfusion recipients and immediate death in 1 of every 500,000 recipients.

These risks are higher than those estimated for transfusion-associated viral infections such as hepatitis C virus or HIV—yet are still likely to be underestimated because bacterial infections attributed to contaminated platelets are underreported, the CDC said.

To reduce this risk, AABB (formerly the American Association of Blood Banks), adopted a new standard in March 2004 requiring member blood banks and transfusion services to implement measures to detect and limit bacterial contamination in all platelet components. Additional guidance for implementation of the standard—aimed at clinicians as well as institutions—was issued in February 2005. It is available at www.aabb.org

A survey conducted last summer by the Infectious Diseases Society of America (IDSA) suggested that awareness of the problem and of the new standard was not high.

The survey was distributed to all 870 infectious-disease consultant members of IDSA's Emerging Infections Network. Of the 399 who responded, only 36% reported being aware that bacterial contamination of platelets was one of the most common infection risks of transfusion therapy, and only 20% indicated having been familiar with the new AABB standard prior to participating in the survey. But, once informed, 90% believed that health care providers should be aware of the standard.

The CDC cited case reports that illustrated the need for awareness and rapid diagnosis of transfusion-associated infections, because false negatives—leading to fatal bacterial sepsis—can occur even when pretransfusion testing complies with the new standard.

In one case, a 74-year-old man with leukemia died of sepsis 21 days after receiving a pooled platelet transfusion. The pooled unit had been tested with a reagent strip to determine pH, a means of detecting bacteria. Even though the sample was in the accepted range, the patient's blood cultures following transfusion grew Staphylococcus aureus.

Although pH tests are an option under the AABB standard, they are less sensitive than culture-based methods. However, even culture-based testing can fail to detect bacterial contamination.