Sunday, August 30, 2009

Update: Novel Influenza A (H1N1) Virus Infections --- Worldwide, May 6, 2009

From Morbidity & Mortality Weekly Report
Published: 08/14/2009

Since mid-April 2009, CDC, state and local health authorities in the United States, the World Health Organization (WHO), and health ministries in several countries have been responding to an outbreak of influenza caused by a novel influenza A (H1N1) virus.[1] In March and early April 2009, Mexico experienced outbreaks of respiratory illness subsequently confirmed by CDC and Canada to be caused by the novel virus. The influenza strain identified in U.S. patients was genetically similar to viruses isolated from patients in Mexico.[2] Since recognition of the novel influenza A (H1N1) virus in Mexico and the United States, as of May 6, a total of 21 additional countries had reported cases, with a total of 1,882 confirmed cases worldwide. Several WHO member states are conducting ongoing investigations of this worldwide outbreak, and WHO is monitoring and compiling surveillance data and case reports. On April 29, WHO raised the level of pandemic alert from phase 4 to phase 5, indicating that human-to-human spread of the virus had occurred in at least two countries in one WHO region. This report provides an update of the initial investigations and spread of novel influenza A (H1N1) virus worldwide.


Since implementing enhanced surveillance on April 17, the number of suspected cases has increased rapidly, along with hospitalizations for severe acute respiratory illness (Figure 1). As of May 5, using an updated case definition of fever plus cough or sore throat for a suspected case and real-time reverse transcription–polymerase chain reaction (rRT-PCR) or viral culture for a laboratory-confirmed case, Mexico had identified 11,932 suspected cases and 949* cases of laboratory-confirmed novel influenza A (H1N1) virus infection, including 42 patients who died. Cases with laboratory-confirmed infection have been identified in 27 of 31 Mexican states and the Federal District. Confirmed cases in Mexico and in the United States have a similar age distribution (Table). Information is available on the clinical course of illness for 22 patients with laboratory-confirmed illness who were hospitalized, including seven patients who died. Five of the 15 surviving patients and one of the seven patients who died had underlying chronic medical conditions. Additional details on the clinical signs and symptoms of these and other patients are being collected. Among patients with confirmed cases for whom information was available, 56 (98%) of 57 reported fever, 49 (94%) of 52 reported cough, 23 (79%) of 29 reported dyspnea, 35 (80%) of 44 reported headache, and 34 of (83%) 41 reported rhinorrhea. The government of Mexico has instituted several measures to slow disease transmission and reduce mortality, including closure of all schools and avoidance of large public gatherings, distribution of oseltamivir to all health-care units, publication of specific clinical guidelines, and establishment of a call center to educate members of the public who are seeking health-care information.

United States
After recognition of the first cases of infection with the novel influenza A (H1N1) virus, CDC and state health departments initiated enhanced surveillance measures to identify additional cases. As of May 6, a total of 1,487 confirmed† and probable cases had been reported from 43 states, including 642 confirmed cases (reported from 41 states) and 845 probable cases (reported from 42 states). Current experience with laboratory testing results indicates that the probability of laboratory confirmation for probable cases is > 99%. States with the most confirmed cases are Illinois (122 cases), New York (97), California (67), Texas (61), and Arizona (48). Dates of illness onset for patients with confirmed or probable illness range from March 28 to May 4 (Figure 2), although the most recent case counts do not account for testing and reporting delays. Among persons with laboratory-confirmed illness, 35 hospitalized patients have been reported from 16 states, including two patients from Texas who died, both with underlying medical conditions. The age distribution of persons with laboratory-confirmed disease ranged from 3 months to 81 years (Table). A total of 18 patients were aged < 2 years, and 31 were aged 2–4 years.

The age distribution of the 35 laboratory-confirmed hospitalized patients ranged from 6 months to 53 years (median: 15 years). Among patients with confirmed disease for whom data were available, 262 (90%) of 292 reported fever, 249 (84%) of 296 reported cough, 176 (61%) of 290 reported sore throat, 65 (26%) of 249 reported diarrhea, and 54 (24%) of 221 reported vomiting.

Other Countries
On April 26, the first cases of novel influenza A (H1N1) virus infection outside of the United States and Mexico were reported in Canada. As of May 6, WHO had reported that 309 persons with laboratory-confirmed disease had been identified in 21 countries other than Mexico and the United States. Confirmed cases have been reported from Asia (Hong Kong S.A.R. and Korea), the Pacific region (New Zealand), the Middle East (Israel), Europe, and Central and South America (El Salvador, Costa Rica, Colombia, and Guatemala) (Figure 3).

Of 178 patients for whom travel history was available, 145 (82%) reported recent travel to Mexico, and four (2%) reported travel to the United States. Among those who had not traveled to Mexico, 17 (52%) reported contact with a returning traveler from Mexico. Canada, Germany, Spain, and the United Kingdom all have reported evidence of in-country, second-generation, human-to-human transmission (e.g., a health-care worker in Germany who had cared for a patient with a confirmed infection). No reports have been made of sustained, community-wide transmission in affected countries. Consistent with cases in North America, most of the cases reported from other countries have been among young adults, with a median age of 27.1 years (range: 2–62 years, N = 45). The majority of cases in other countries have been uncomplicated, and no deaths have been reported; four patients have been hospitalized.§

Editorial Note

Early surveillance data from this outbreak suggest that the novel influenza A (H1N1) virus has the potential for efficient, rapid spread among countries. Although the illness associated with infection generally seems self-limited and uncomplicated, a substantial number of cases of severe disease and death has been reported in previously healthy young adults and children. Several characteristics of this outbreak appear unusual compared with a typical influenza seasonal outbreak. First, the percentage of patients requiring hospitalization appears to be higher than would be expected during a typical influenza season.[3] Second, the age distribution of hospitalizations for novel influenza A (H1N1) virus infection is different than that of hospitalizations for seasonal influenza, which typically occur among children aged < 2 years, adults aged > 65 years, and persons with chronic health conditions.[3] In Mexico and the United States, the percentage of patients requiring hospitalization has been particularly high among persons aged 30–44 years.

Two deaths have been reported in the United States, resulting in a preliminary case-fatality rate of 0.2% among patients with laboratory-confirmed disease. However, such case-fatality rates should be viewed with caution. The actual case-fatality rate is difficult to ascertain in a rapidly evolving outbreak because an unknown proportion of currently infected patients might die, denominators might be uncertain because of unreported cases, and groups at high risk for death from seasonal influenza (e.g., older adults and patients with chronic disease) might not yet have been exposed to the novel influenza A (H1N1) virus.

Summertime influenza outbreaks in temperate climates have been reported in closed communities such as prisons, nursing homes, cruise ships, and other settings with close contact.[4–8] Such outbreaks typically do not result in community-wide transmission, but they can be important indicators of viruses likely to circulate in the upcoming influenza season.[8] The novel influenza A (H1N1) virus has been circulating in North America largely after the peak influenza transmission season. For that reason, the epidemiology and severity of the upcoming influenza season in the southern hemisphere or in the northern hemisphere cannot be predicted. The imminent onset of the season for influenza virus transmission in the southern hemisphere, coupled with detection of confirmed cases in several countries in the southern zone, raise concern that spread of novel influenza A (H1N1) virus might result in large-scale outbreaks during upcoming months. Countries in the southern hemisphere that are entering the influenza season should anticipate outbreaks and enhance surveillance accordingly. Influenza virus can circulate year round in tropical regions; therefore, these countries should maintain enhanced surveillance for novel influenza A (H1N1) virus.

Studies in countries affected by the novel influenza A (H1N1) virus should help guide surveillance, case management, and prevention strategies in countries not yet affected. Key concerns that should be addressed in these studies include assessment of the potential impact on public health; clinical progression of disease, including rates and types of complications for different age and risk groups; and information on virus transmissibility. Assessment of potential disease severity associated with this novel virus will help inform decisions on prevention strategies to slow the spread of infection. Effective control measures will depend on the ability of national governments to quickly gather and share virologic, epidemiologic, and clinical information from multiple sources as new cases appear.

Reported by: General Directorate of Epidemiology, Ministry of Health, Mexico; Pan American Health Organization; World Health Organization; Public Health Agency of Canada; Influenza Div, National Center for Immunization and Respiratory Diseases, CDC Influenza Emergency Response Team, CDC.

* As of May 6, 2009, the number of laboratory-confirmed cases had increased to 1,112.
† Case definition available at
§ Additional information is available at

Overweight and Obesity Linked to Lower Brain Volume

From Medscape Medical News
Caroline Cassels

August 28, 2009 — Overweight and obese individuals have significantly lower brain volume than their normal-weight counterparts, a finding researchers say puts these individuals at much greater risk for dementia, including Alzheimer's disease.

Results from a new imaging study reveal that, on average, obese subjects had 8% lower brain volume than normal-weight subjects and overweight subjects had 4% lower brain volume.

"That's a big loss of tissue and it depletes your cognitive reserves, putting you at much greater risk of Alzheimer's and other diseases that attack the brain," principal investigator Paul M. Thompson, PhD, from the Lab of Neuro Imaging, UCLA School of Medicine, in Los Angeles, California, said in a statement.

The study was published online August 6 in Human Brain Mapping.

Worldwide Problem

It is well known that obesity increases the risk for cardiovascular illness, including diabetes, hypertension, and stroke, all of which increase the risk for cognitive decline and dementia. However, the authors point out, it is not known whether these factors, specifically obesity and type 2 diabetes, are associated with specific patterns of brain atrophy.

The authors note that there are currently more than 1 billion overweight and 300 million obese individuals worldwide. In addition, 40% of men and 45% of women older than 70 years are either obese or have type 2 diabetes.

To examine gray- and white-matter volume differences in elderly subjects, the researchers used tensor-based morphometry to examine gray- and white-matter volume differences in 94 elderly subjects who remained cognitively normal for a minimum of 5 years after their scan.

Researchers used participants in the Cardiovascular Health Study (CHS) Cognition Study, a continuation of the CHS Dementia Study, which began in 2002/2003, to determine the incidence of dementia and mild cognitive impairment in a population of normal and mild cognitive-impairment-subjects identified in 1998/1999.

To define weight categories, they used the body mass index (BMI). Normal weight was defined as a BMI of 18.5 to 25.0 kg/m2; overweight was defined as a BMI of 25 to 30 kg/m2, and obese was defined as a BMI greater than 30 kg/m2. Subjects were classified as having type 2 diabetes if they met any 1 of the standard criteria for the disease.

Of the total study sample, 29 participants were normal weight, 51 were overweight, and 14 were obese.

Aging Effect

Multiple regression analyses revealed that BMI was negatively correlated with brain atrophy, and that type 2 diabetes and fasting plasma insulin levels were not. Specifically, the investigators found that a higher level of body tissue was associated with brain-tissue loss in the frontal and temporal lobes, the anterior cingulate gyrus, the hippocampus, and the basal ganglia.

Overweight individuals had brain loss in the basal ganglia, the corona radiate, and the parietal lobe. The authors report that negative correlations between body-tissue fat and brain structure were strongest in obese people, but were also seen in overweight people.

"The brains of obese people looked 16 years older than the brains of those who were lean, and in overweight people they looked 8 years older," said Dr. Thompson.

"It seems that, along with increased risk for health problems such as such type 2 diabetes and heart disease, obesity is bad for your brain. We have linked it to the shrinkage of brain areas that are targeted by Alzheimer's disease," study investigator Cyrus A. Raji, MD, from the University of Pittsburgh School of Medicine in Pennsylvania, said in a statement. "But that could mean that exercising, eating right, and keeping weight under control can maintain brain health with aging and potentially lower the risk for Alzheimer's and other dementias."

The researchers have disclosed no relevant financial relationships.

Hum Brain Mapp. Published online before print August 6, 2009. Abstract

Hong Kong Health Care Workers Leery of H1N1 Vaccine

From Reuters Health Information

NEW YORK (Reuters Health) Aug 26 - Even though testing has so far raised no "red flags" regarding safety of vaccines against the novel H1N1 influenza virus, surveys and focus groups show that healthcare workers and members of the public may be leery of being inoculated when supplies become available this fall.

Writing in the August 26 issue of BMJ Online First, Dr. Paul K. S. Chan and associates at the Chinese University of Hong Kong note that "in nearly all countries with a (pandemic) preparedness plan, healthcare workers are listed as the priority group for mass vaccination."

In May of this year when the WHO pandemic influenza alert level had been raised to phase 5, the researchers distributed 810 questionnaires to public hospital workers, primarily doctors and nurses.

A tally of the 389 questionnaires that were returned indicated that less than half (48%) intended to accept pre-pandemic H1N1 vaccination. The most common reason for refusal was worry over side effects, follow by questions about the vaccine's efficacy and the conviction that it was "not yet the right time to be vaccinated."

"This is particularly surprising in a city where the SARS outbreak had such a huge impact," Dr. Chan's team points out.

The strongest associations with willingness to be vaccinated, the report indicates, were a history of seasonal flu vaccination and the perception that they were likely to be infected.

In a linked commentary, Dr. Rachel Jordan, from the University of Birmingham, and Dr. Andrew Hayward, from the University College of London, advise that in order to maximize vaccine uptake, "use of convenient mobile systems, monitoring and feedback systems, and 'opt-out' systems (where healthcare workers need to indicate their reasons for not accepting the vaccine) show promise."

In a separate article published online in the Emerging Health Threats Journal, Dr. Natalie Henrich of the University of British Columbia and Dr. Bev J. Holmes at Simon Fraser University, both in Vancouver, describe findings from 11 focus groups conducted with the public in Vancouver, Canada, in 2006 and 2007 to explore their willingness to use novel vaccines in a pandemic.

The researchers asked the 85 participants how willing they would be to accept a new vaccine in the event of a pandemic. Very few people said they or their children would definitely get vaccinated, the authors report. Participants' concerns centered around the risk of infection versus the risks involved in using newly developed vaccines.

"Participants were hesitant to use the novel vaccines (due to) concern that unsafe pharmaceuticals may be rushed to market during the health crisis," the authors said.

Instead, many individuals believed they could protect themselves through their own behavior, including frequent handwashing, staying away from crowded places and sick people, and eating well to maintain their strong immune system.

BMJ 2009;339:b3391.

Emerging Health Threats Journal 2009.

WHO Issues Guidelines for Antiviral Treatment for H1N1 and Other Influenza

From Medscape Medical News

Laurie Barclay, MD

August 25, 2009 — The World Health Organization (WHO) has issued guidelines for antiviral treatment for novel influenza A (H1N1) and other influenza. The purpose of the new recommendations, which were posted online August 20, is to provide a basis for advice to clinicians regarding the use of the currently available antivirals for patients presenting with illness caused by influenza virus infection, as well as considerations regarding potential use of these antiviral medications for chemoprophylaxis.

On the basis of a review of data collected with previously circulating strains, and treatment of human H5N1 influenza virus infections, the new guidelines expand on recommendations published in May 2009, titled ʺClinical management of human infection with new influenza A (H1N1) virus: Initial guidance." These new guidelines do not change recommendations in the WHO rapid advice guidelines on pharmacological management of humans infected with highly pathogenic avian influenza A (H5N1) virus.

"In April 2009, the [WHO] received reports of sustained person to person infections with [H1N1] virus in Mexico and the United States," write Edgar Bautista, from Médico Neumólogo Intensivista, Jefe de UCI-INER in Mexico, and colleagues. "Subsequent international spread led WHO to declare on 11 June 2009 that the first influenza pandemic in 41 years had occurred. This 2009 pandemic H1N1 influenza virus has now spread worldwide, with confirmed cases of pandemic H1N1 virus infection reported in more than 100 countries in all 6 WHO regions[, which] has led to the need to add to the existing guidance on the use of antivirals."

The new recommendations highlight oseltamivir and zanamivir, which are neuraminidase inhibitors, and amantadine and rimantadine, which are M2 inhibitors. Suggestions are also provided regarding the use of some other potential pharmacological treatments, such as ribavirin, interferons, immunoglobulins, and corticosteroids.

Management of patients with pandemic influenza (H1N1) 2009 virus infection is the primary focus of the statement, although it also includes guidance regarding the use of the antivirals for treatment of other seasonal influenza virus strains, as well as for infections resulting from novel influenza A virus strains.

The guidelines urge country and local public health authorities to issue local recommendations for clinicians periodically, based on epidemiological and antiviral susceptibility data on the locally circulating influenza strains. As the prevalence and severity of the current pandemic evolves, WHO anticipates that additional data will be forthcoming that may require revision of the current recommendations. WHO therefore plans to review the guidance no later than September 2009 to determine whether modifications to the recommendations are needed.

Recommendations for Antiviral Treatment of H1N1

For patients with confirmed or strongly suspected infection with influenza pandemic (H1N1) 2009, when antiviral medications for influenza are available, specific recommendations regarding use of antivirals for treatment of pandemic (H1N1) 2009 influenza virus infection are as follows:

Oseltamivir should be prescribed, and treatment started as soon as possible, for patients with severe or progressive clinical illness (strong recommendation, low-quality evidence). Depending on clinical response, higher doses of up to 150 mg twice daily and longer duration of treatment may be indicated. This recommendation is intended for all patient groups, including pregnant women, neonates, and children younger than 5 years of age.

Zanamivir is indicated for patients with severe or progressive clinical illness when oseltamivir is not available or not possible to use, or when the virus is resistant to oseltamivir but known or likely to be susceptible to zanamivir (strong recommendation, very low quality evidence).

Antiviral treatment is not required in patients not in at-risk groups who have uncomplicated illness caused by confirmed or strongly suspected influenza virus infection (weak recommendation, low-quality evidence).

Patients considered to be at risk are:
infants and children younger than 5 years of age;
adults older than 65 years of age;
nursing home residents;
pregnant women;
patients with chronic comorbid disease including cardiovascular, respiratory, or liver disease and diabetes;
immunosuppressed patients because of malignancy, HIV infection, or other diseases.

Oseltamivir or zanamivir treatment should be started as soon as possible after the onset of illness in patients in at-risk groups who have uncomplicated illness caused by influenza virus infection (strong recommendation, very low quality evidence).

Recommendations for Chemoprophylaxis of H1N1

Specific recommendations regarding the use of antivirals for chemoprophylaxis of pandemic (H1N1) 2009 influenza virus infection are as follows:

When risk for human-to-human transmission of influenza is high or low, and the probability of complications of infection is high, either because of the influenza strain or because of the baseline risk of the exposed group, use of oseltamivir or zanamivir may be considered as postexposure chemoprophylaxis for the affected community or group, for individuals in at-risk groups, or for healthcare workers (weak recommendation, moderate-quality evidence).

Individuals in at-risk groups or healthcare personnel need not be offered antiviral chemoprophylaxis if the likelihood of complications of infection is low. This recommendation should be applied independent of risk for human-to-human transmission (weak recommendation, low-quality evidence).

For treatment of mild to moderate uncomplicated clinical presentation of infection with multiple cocirculating influenza A subtypes or viruses with different antiviral susceptibilities, patients in at-risk groups should be treated with zanamivir or oseltamivir plus M2 inhibitor (noting that amantadine should not be used in pregnant women). Otherwise-healthy patients with this presentation need not be treated.

When the clinical presentation of infection with multiple cocirculating influenza A subtypes or viruses with different antiviral susceptibilities is severe or progressive, all patients should be treated with oseltamivir plus M2 inhibitor, or zanamivir.

For treatment of mild to moderate uncomplicated clinical presentation of infection with sporadic zoonotic influenza A viruses including H5N1, the at-risk population should be treated with oseltamivir or zanamivir, and the otherwise-healthy population with oseltamivir. All patients, regardless of risk status, with severe or progressive presentation of infection with sporadic zoonotic influenza A viruses including H5N1 should be treated with oseltamivir plus an M2 inhibitor.

WHO Rapid Advice Guidelines on Pharmacological Management of Influenza Virus. Published online August 20, 2009.

Friday, August 14, 2009

More Water, Fewer Sweetened Beverages: Effects on Children

From Medscape Pediatrics > Viewpoints
William T. Basco, Jr., MD, FAAP

Read more Promotion and Provision of Drinking Water in Schools for Overweight Prevention: Randomized, Controlled Cluster Trial
Muckelbauer R, Libuda L, Clausen K, Toschke AM, Reinehr T, Kersting M
Pediatrics. 2009;123:e661-e667

The study authors sought to reduce childhood obesity through a community-wide approach. They noted that previous randomized studies had demonstrated that altering caloric intake via changing beverage types appears to be a successful method to moderate weight gain.

The study authors conducted a randomized controlled (cluster) trial that both encouraged increased intake of water and made water readily available at schools in Germany. The subjects were in the second or third grades and attended elementary schools in low-income, urban areas. There were 17 schools (1641 children) in the intervention group and 15 schools (1309 children) in the control group. The study took place during the 2006-2007 school year.

The intervention consisted of the following: installation of a new water fountain in the school (2 if the school was big enough); provision of a plastic water bottle to each child; instruction to teachers to facilitate having the children fill water bottles each morning (at school); and delivery by teachers of 4 standardized lessons over the course of the academic year (45 minutes each lesson) on water needs.

Investigators measured the children's height and weight at enrollment and at follow-up in order to calculate their body mass indices. The study authors were interested in obesity prevalence as the primary outcome. The subjects completed 24-hour recall questionnaires to record beverage consumption (volume and type) at enrollment and at follow-up.

In the final analyses, the study authors controlled for subject weight at baseline and sex. Baseline juice consumption was slightly higher in the intervention groups (by 0.2 glasses per day), but the groups were otherwise very similar at enrollment. At enrollment, the intervention group had a 23.4% prevalence of overweight, and the control group 25.9%, but this difference was not significant (P = .21). However, at the end of the intervention, 23.5% (increase of 0.1 percentage point) of the intervention group and 27.8% (increase of 1.9 percentage points) of the control group were obese, and this difference was significant ( odds ratio for obesity in intervention, 0.69; 95% confidence interval, 0.48-0.98).

On average, the intervention group increased water consumption by 1.1 glasses per day over the control group. There were no effects on either change in juice or soft drink consumption between the groups. The study authors concluded that this combined educational and environmental intervention was effective in preventing overweight.

Impact of Change in Sweetened Caloric Beverage Consumption on Energy Intake Among Children and Adolescents
Wang YC, Ludwig DS, Sonneville K, Gortmaker SL
Arch Pediatr Adolesc Med. 2009;163:336-343

The study authors utilized 2003-2004 data from the National Health and Nutrition Examination Survey to estimate daily caloric intake due to sweetened beverages. They determined that subjects derived 35% of their beverage intake from sweetened beverages and that replacing those with water would reduce daily caloric intake by 235 kcal.

Just as reductions in cigarette smoking have been mostly achieved through societal approaches (limiting advertising, increasing prices, and limiting access, for example), interventions to reduce obesity may be most successful when attempted on larger scales. The first study by Muckelbauer and colleagues is a large-scale project with promising results. It demonstrated the potential value of advocating for healthy choices and education in local schools. It should also give some encouragement to practitioners who are "slugging it out" on a daily basis, attempting to educate parents and children about healthy food choices to limit weight gain. In addition, the second study by Wang and colleagues also offers good numbers to support this fight, with estimates of a substantial reduction in calories (over 10% of total daily caloric intake in that study) if children would replace all sweetened beverages with water.

Probiotics May Be Useful Against Colds, Flu-Like Symptoms in Children

From Medscape Medical News
Laurie Barclay, MD

August 12, 2009 — Probiotics may be useful as prophylaxis against cold and influenza-like symptoms in children, according to the results of a double-blind, placebo-controlled study reported in the August issue of Pediatrics.

"Selected strains of probiotics have been tested for human health benefits in a variety of disease conditions, but much less is known regarding prophylactic benefits in healthy populations," write Gregory J. Leyer, PhD, from Danisco in Madison, Wisconsin, and colleagues. "This study adds information supporting the use of the probiotics tested for prophylaxis against cold and influenza-like symptoms and compares the efficacy of 1-strain and 2-strain preparations."

The effects of probiotic intake on incidence and duration of cold and influenza-like symptoms during the winter season were evaluated in healthy children aged 3 to 5 years. Of 326 eligible children, 104 were randomly assigned to receive placebo, 110 to Lactobacillus acidophilus NCFM, and 112 to L acidophilus NCFM in combination with Bifidobacterium animalis subsp lactis Bi-07. Children were treated twice daily for 6 months.

Compared with the placebo group, the groups receiving single and combination probiotics fared significantly better in several outcomes. Fever incidence was 53.0% lower with single probiotics (P = .0085) and 72.7% lower with combination probiotics (P = .0009); coughing incidence 41.4% (P = .027) and 62.1% (P = .005) lower; and rhinorrhea incidence 28.2% (P = .68) and 58.8% (P =.03) lower, respectively.

Fever, coughing, and rhinorrhea duration were 32% lower with single strain vs placebo (P = .0023) and 48% lower with the strain combination (P < .001). Antibiotic use incidence was 68.4% lower for single strain vs placebo (P = .0002) and 84.2% lower for the strain combination (P < .0001). Days absent from group child care were also 31.8% lower for single strain vs placebo (P =.002) and 27.7% lower for the strain combination (P < .001).

"Daily dietary probiotic supplementation for 6 months was a safe effective way to reduce fever, rhinorrhea, and cough incidence and duration and antibiotic prescription incidence, as well as the number of missed school days attributable to illness, for children 3 to 5 years of age," the study authors write. "No notable adverse events were attributed to study probiotic strains."

Limitations of this study include failure to evaluate mucosal colonization, underlying mechanisms, or the effect of probiotics in an acute response to signs of illness.

"Daily probiotic dietary supplementation during the winter months was a safe effective way to reduce episodes of fever, rhinorrhea, and cough, the cumulative duration of those symptoms, the incidence of antibiotic prescriptions, and the number of missed school days attributable to illness," the study authors conclude. "L acidophilus NCFM alone was effective. There was, however, a trend for a broader protective effect with the combination of L acidophilus NCFM and B lactis Bi-07."

Danisco USA sponsored this study, employs 2 of the study authors, and has contracted 3 other authors regarding this study.

Pediatrics. 2009;124:e172-e179. Abstract

Tuesday, August 11, 2009

H1N1 news update from Malaysian Medical Association Sarawak

letter from MMA Sarawak Branch Chairman to GPs

1) Over 90% of confirmed flu cases in Malaysia are now due to H1N1.
2) SGH is only sending sample for confirmatory testing for those will serious complications such as pneumonia to avoid overloading the system. It is taking 3 days for the result.
3) The death rate in Malaysia is now 0.8%. (Death/confirmed cases. Actual mortality is probably lower as many mild cases are not tested.)
4) Tamiflu is effective treatment but treatment need to be started within 48 hrs of symptom onset. It is difficult to obtain original Tamiflu from Roche. Generic Tamiflu ( Flu halt) is available from Ranbaxy but it cost about RM 150/ course. (more expensive than original!)
5) For practical purpose, if a patient demand Flu testing, you can take a throat swab and send to lab to test for Influenza. If +ve, > 90% chance of it being H1N1. But the test is only 70-75% sensitive.
6) please advise isolation and give at least 3 days sick leave. ( ideally 7 days from onset of symptoms.)
7) From the experience of Australia and New Zealand, those that require ventilation are ventilated for 2-3 weeks. If we don't try to slow down the spread, we might run out of ventilator!

Soon Su Yang
Chairman, MMA Sarawak

Sunday, August 9, 2009

Ambulatory Treatment Feasible for Infants With Febrile Urinary Tract Infections

From Medscape Medical News

Laurie Barclay, MD
Charles P. Vega, MD, FAAFP

July 13, 2009 — Ambulatory treatment is feasible for infants aged 30 to 90 days with febrile urinary tract infections (UTIs), according to the results of a cohort study reported in the July issue of Pediatrics.

"It is common practice to hospitalize 1- to 3-month-old infants with febrile UTIs and to treat them with intravenously administered antibiotics," write Marie-Joëlle Doré-Bergeron, MD, from Sainte-Justine University Hospital Center, University of Montreal in Quebec, Canada, and colleagues. "This is the first study to examine ambulatory treatment with short-term, intravenous antibiotic therapy for young infants with febrile UTIs. This treatment option is feasible and may reduce significantly the number of hospital admissions for UTIs in this age group."

Between January 1, 2005, and September 30, 2007, a total of 118 children aged 30 to 90 days were seen for presumed febrile UTIs in the emergency department of a tertiary-care pediatric hospital and enrolled in this study. Of these, 67 (56.8%) were given intravenously administered antibiotics as outpatients in a day treatment center, and 51 (43.2%) met exclusion criteria and were hospitalized.

For those infants treated in the day treatment center, median age was 66 days (age range, 33 - 85 days), and the diagnosis of UTI was confirmed for 86.6% of patients. Urine culture results were positive for Escherichia coli in 84.5% of infants, and 98.3% of isolates were sensitive to gentamicin. Six infants (10.3%) had positive blood culture results, including 5 that were positive for E coli.

Mean duration of intravenous antibiotic treatment in the day treatment center was 2.7 days, and mean number of visits was 2.9, including appointments for voiding cystourethrography. The rate of parental compliance with day treatment center visits was 98.3%, and 8.6% of infants had problems with intravenous access. Of patients with confirmed UTIs, 86.2% underwent successful treatment in the day treatment center, defined as attendance at all visits, temperature normalization within 48 hours, negative control urine and blood culture results if cultures were performed, and no hospitalization from the day treatment center.

Limitations of this study include lack of generalizability to less intensively monitored care settings.

"Ambulatory treatment of infants 30 to 90 days of age with febrile urinary tract infections by using short-term, intravenous antibiotic therapy at a day treatment center is feasible," the study authors write. "Excellent parental compliance can be achieved in this setting, which allows close medical supervision. During the wait for more evidence on the safety of oral antibiotic therapy for very young infants with UTIs, this approach may reduce significantly the number of hospital admissions for UTI treatment in this age group."

The study authors have disclosed no relevant financial relationships.

Pediatrics. 2009;124:16-22.

Clinical Context

UTI can be a serious illness, particularly among young children, and the authors of the current study provide a review of the workup and management of UTIs. Bacteremia associated with UTI is most common among infants younger than 2 months, when the prevalence of bacteremia secondary to UTI may exceed 20%. However, there are few symptoms and signs to alert the clinician as to which child has bacteremia in the presence of a UTI. Thus, the standard of care calls for intravenous antibiotic therapy against gram-negative organisms for the initial treatment of UTIs among infants. Some research has found that oral antibiotic therapy is equally effective as parenteral therapy followed by oral treatment, but this result is not as well documented among infants.

The current study compares an outpatient-based treatment strategy for UTI vs inpatient treatment among infants between the ages of 1 to 3 months.

ACIP Updates Recommendations for Routine Poliovirus Vaccination

From Medscape Medical News
Laurie Barclay, MD

August 7, 2009 — The Advisory Committee on Immunization Practices (ACIP) has updated its recommendations for routine poliovirus vaccination and published them in the August 7 issue of the Morbidity and Mortality Weekly Report.

The goals of the update are to highlight the importance of the booster dose in children older than 4 years, to extend the minimum interval between dose 3 and dose 4 from 4 weeks to 6 months, to include a new precaution regarding use of minimum intervals in the first 6 months of life, and to recommend schedules for poliovirus vaccination with specific combination vaccines.

"On June 17, 1999, ACIP recommended that all poliovirus vaccine administered in the United States be an inactivated poliovirus vaccine (IPV) beginning January 1, 2000," the report states. "This policy was implemented to eliminate the risk for vaccine-associated paralytic poliomyelitis, a rare condition that has been associated with use of the live oral poliovirus vaccine.... Since 1999, no [oral poliovirus vaccine] has been distributed in the United States."

The 1999 ACIP recommendations specified a routine IPV vaccination schedule of 4 doses given at ages 2 months, 4 months, 6 to 18 months, and 4 to 6 years, with 4 weeks being the minimum interval between all IPV doses. In the United States, 3 different combination vaccines containing IPV have been licensed for routine use since the 2000 ACIP recommendation was made in1999.

The updated ACIP guidelines now include the following recommendations to avoid potential confusion related to using different vaccine products for routine and catch-up immunization:

•The 4-dose IPV series should still be given at ages 2 months, 4 months, 6 to 18 months, and 4 to 6 years.
•Regardless of the number of previous doses, the final dose in the IPV series should be given at age older than 4 years.
•Between dose 3 and dose 4, the minimum interval is increased from 4 weeks to 6 months.
•Between dose 1 and dose 2, and between dose 2 and dose 3, the minimum interval is still 4 weeks.
•For dose 1, the minimum age is still 6 weeks.
Another new ACIP recommendation is that use of the minimum age and minimum intervals for vaccination in the first 6 months of life are recommended only if the vaccine recipient is at risk for imminent exposure to circulating poliovirus; for example, during an outbreak or for travel to a polio-endemic region. The rationale for this new precaution is that shorter intervals and earlier start dates result in lower seroconversion rates.

ACIP is also recommending a poliovirus vaccination schedule with specific combination vaccines, as follows:

•When DTaP-IPV/Hib (Pentacel, Sanofi Pasteur) is given at ages 2, 4, 6, and 15 to 18 months (4 doses total), children should receive an additional booster dose of age-appropriate IPV-containing vaccine (IPV [Ipol, Sanofi Pasteur] or DTaP-IPV [Kinrix, GlaxoSmithKline]) at age 4 to 6 years, resulting in a 5-dose IPV vaccine series.
•The booster dose at age 4 to 6 years should not be DTaP-IPV/Hib.
•For optimal booster response, the minimum interval between dose 4 and dose 5 should be at least 6 months.
•As per current recommendations, a booster dose should be given as soon as feasible to a child missing an IPV dose at age 4 to 6 years.

Morb Mortal Wkly Rep. 2009;58:829–830.

Saturday, August 8, 2009

CT Scans May Not Be Helpful for Most Young Children With Emergent Headache

From Medscape Medical News

July 29, 2009 — Computed tomographic (CT) scans seldom lead to diagnosis or contribute to immediate management of young children presenting to the emergency department with headache but normal neurologic examination findings and nonworrying history, according to the results of a study reported in the July issue of Pediatrics.

"Neuroimaging because of recurrent childhood headaches has limited value; especially in the setting of normal physical examination," write Tarannum M. Lateef, MD, from George Washington University School of Medicine and Children's National Medical Center in Washington, DC, and colleagues. "The risk of radiation exposure from CT scans is highest in the youngest age group. This study addresses the diagnostic utility of CT scans, in an ED [emergency department] setting, for children <6 years of age."

The investigators evaluated the records of 364 children aged 2 to 5 years seen between July 1, 2003, and June 30, 2006, in a large urban emergency department for evaluation of headache. Patients with headaches secondary to clearly apparent causes such as ventriculoperitoneal shunts, known brain tumor, or acute illnesses including viral syndromes, fever, probable meningitis, or trauma were identified based on initial history and examination findings. For the remaining patients, headache history, neurologic findings, results of laboratory and neuroimaging tests, discharge diagnosis, and disposition were reviewed.

Among 306 children (84%) with secondary headaches identified from initial history and physical examination, acute febrile illnesses, and viral respiratory tract syndromes were thought to be responsible for the headaches in 72%.

CT scans were performed in 16 (28%) of the 58 children (16% of the total study sample) with no evident central nervous system disease or systemic illness diagnosed at presentation. In 15 (94%) of these 16 patients, CT scans did not facilitate diagnosis or management. Only 1 scan result was abnormal, revealing a brainstem glioma, but this patient had abnormal findings on neurologic examination when first evaluated in the emergency department. Family history was not documented in 59% of children who were thought to have primary headaches.

"For young children presenting to the ED with headache but normal neurologic examination findings and nonworrying history, CT scans seldom lead to diagnosis or contribute to immediate management," the study authors write. "A family history often is contributory and should be part of the evaluation of young children with headache in the ED. CT imaging poses risk (which is greatest for the youngest children), is expensive, and usually is without benefit."

Limitations of this study include retrospective design, lack of complete follow-up monitoring, and analysis limited to information in clinical records. Most children studied did not have a documented family history or a thorough headache history.

"Studies such as this one can contribute to recognition of medical interventions for which indications need rethinking," the study authors conclude.

Thursday, August 6, 2009

Recognizing Child Abuse: Slideshow

Learn how to identify telltale findings of child abuse from patient history and physical and radiographic examination while avoiding false accusations and losing the trust of the patient's family.