About the Center for Drug Evaluation and Research > Peginterferon alfa-2b

U. S. Food and Drug Administration approved peginterferon alfa-2b (Sylatron, Schering Corporation, Kenilworth, NJ 07033), for the treatment of patients with melanoma with microscopic or gross nodal involvement within 84 days of definitive surgical resection including complete lymphadenectomy. (March 29, 2011) More Information: http://www.fda.gov/AboutFDA/CentersOffices/CDER/ucm249263.htm


About the Center for Drug Evaluation and Research > Peginterferon alfa-2b

New strategic plan for NIH obesity research seeks to curb epidemic, March 31, 2011 News Release - National Institutes of Health (NIH)

Thursday, March 31, 2011
9 a.m. EDT Contact:
NIDDK Home : NIDDK
Amy F. Reiter
NIDDKMedia@mail.nih.gov
301-496-3583



New strategic plan for NIH obesity research seeks to curb epidemic
Researchers, health care professionals, the public create comprehensive plan

To combat the obesity epidemic, the National Institutes of Health is encouraging diverse scientific investigations through a new Strategic Plan for NIH Obesity Research.

More than one-third of adults in the United States and nearly 17 percent of the nation’s children are now obese, which increases a person’s chance of developing many health problems, including type 2 diabetes, heart disease, high blood pressure, fatty liver disease, and some cancers. In 2008, obesity-related medical costs were an estimated $147 billion. Government, nonprofit and community groups, businesses, health care professionals, schools, families, and individuals are taking action to address this public health problem — and research can provide the foundation for these efforts.

NIH funds research to reduce the prevalence of obesity and its health consequences, an investment of $824 million in fiscal year 2010, plus awards totaling $147 million made in the same year through the Recovery Act. This NIH strategic plan, developed by the NIH Obesity Research Task Force, recognizes that eating less and exercising more is easier said than done. Highlighting the crucial role of research in efforts to reduce obesity, the plan emphasizes moving science from laboratory to clinical trials to practical solutions, and is designed to help target efforts and resources in areas most likely to help.

“Obesity has many causes and contributing factors. This plan is a bold blueprint that will encourage the research community to examine the epidemic of obesity from diverse perspectives,” said NIH Director Francis S. Collins, M.D., Ph.D. “Through the scientific opportunities outlined in the strategic plan, researchers can work together toward the goals of preventing and treating obesity, to help people lead healthier and more fulfilling lives.”

The task force is co-chaired by Griffin P. Rodgers, M.D., director of the National Institute of Diabetes and Digestive and Kidney Diseases; Susan B. Shurin, M.D., acting director of the National Heart, Lung, and Blood Institute; and Alan E. Guttmacher, M.D., director of the Eunice Kennedy Shriver National Institute of Child Health and Human Development. These three institutes, along with the National Cancer Institute, led in the plan’s development.

The research recommendations include:

•discover key processes that regulate body weight and influence behavior
•understand the factors that contribute to obesity and its consequences
•design and test new approaches for achieving and maintaining a healthy weight
•evaluate promising strategies to prevent and treat obesity in real-world settings and diverse populations
•use technology to advance obesity research and improve healthcare delivery

To increase the reach of research and improve public health, the plan also highlights education and outreach to move proven strategies into community programs and medical practice.

Since the release of the first strategic plan in 2004, research produced many advances, including:

•Lifestyle interventions for weight loss reduce risk for heart disease and type 2 diabetes. NIH-funded studies are testing ways to bring these proven strategies to more people.
•When a woman with obesity or diabetes becomes pregnant, her child’s risk of developing obesity may increase, suggesting a critical period to intervene. Researchers can study approaches to help women achieve a healthy weight before and during pregnancy.
•Many genes and other aspects of our biology, from body fat to the gastrointestinal system and brain, influence whether we’re likely to become obese. Researchers are delving deeper into these pathways and how they’re affected by our environment.
While research continues, NIH resources can help people achieve or maintain a healthy weight now. Find tips and tools from the Weight-control Information Network at www.win.niddk.nih.gov, from Aim for a Healthy Weight at http://healthyweight.nhlbi.nih.gov, and from We Can! — or Ways to Enhance Children’s Activity & Nutrition — at http://wecan.nhlbi.nih.gov. The Let’s Move campaign, led by the White House, also provides valuable ways to prevent childhood obesity at www.LetsMove.gov.

Learn more about obesity research at NIH, see a video about the plan from Collins, and view or request a free copy of the summary or complete Strategic Plan for NIH Obesity Research at www.obesityresearch.nih.gov.

The National Institutes of Health (NIH) — The Nation's Medical Research Agency — includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. It is the primary federal agency for conducting and supporting basic, clinical and translational medical research, and it investigates the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov.


---------------------------------
The activities described in this release are being funded through the American Recovery and Reinvestment Act. More information about NIH’s Recovery Act grant funding opportunities can be found at http://grants.nih.gov/recovery. To track the progress of HHS activities funded through the Recovery Act, visit www.hhs.gov/recovery. To track all federal funds provided through the Recovery Act, visit www.recovery.gov.
---------------------------------
New strategic plan for NIH obesity research seeks to curb epidemic, March 31, 2011 News Release - National Institutes of Health (NIH)

EL BIRUNI: DIRECTORIO DE DOCUMENTOS EDITADOS EN MARZO 2011 [*]

jueves 31 de marzo de 2011
EL BIRUNI: DIRECTORIO DE DOCUMENTOS EDITADOS EN MARZO 2011 [*]
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Consultas acumuladas desde enero 2009 a la fecha: 327.515
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Discriminadas como sigue:
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6. PERÚ: 16.542 [ 5,1%]
7. VENEZUELA: 15.629 [ 4,8%]
8. CHILE: 10.570 [ 3,2%]
9. ECUADOR: 7.262 [ 2,2%]
10. U.K.: 5.075 [ 1,5%]
11. LOS DEMÁS: 73.073 [22,3%]
Total de consultas: 327.515


Documentos del mes de MARZO 2011: 704
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MUESTRA ESTADÍSTICA (de un día): (al 31 de marzo de 2011)
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Archivo del blog

1. ▼ 2011 (1968)
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Announcements: STD Awareness Month --- April 2011

Announcements: STD Awareness Month --- April 2011
Weekly
April 1, 2011 / 60(12);380




April is STD Awareness Month, an annual observance to raise public awareness about the impact of sexually transmitted diseases (STDs) on the lives of persons in the United States and the importance of discussing sexual health with health-care providers and sex partners. This STD Awareness Month's focus is on the importance of young persons getting tested. Even though they make up only 25% of the sexually active population, persons aged 15--24 years account for nearly half of the 19 million new STD cases each year (1). Undetected and untreated STDs can increase a person's risk for human immunodeficiency virus (HIV) infection and cause other serious health consequences, such as infertility. STD screening can help detect disease early and, when combined with treatment, is one of the most effective tools available to protect one's health and prevent the spread of STDs to others.

To increase STD screening among young persons, CDC is partnering again with MTV, the Kaiser Family Foundation, the Planned Parenthood Federation of America, and other partners on the GYT (Get Yourself Tested) campaign. This year, the GYT website (http://www.gytnow.org) is offering resources for health-care providers to help them better serve their teen and young adult patients. CDC continues to update its interactive STD and HIV testing locator on the National HIV and STD Testing Resource website (http://www.findstdtest.org). CDC's STD Awareness Resource Site (http://www.cdcnpin.org/stdawareness) provides STD prevention partners with information and tools to support their local STD Awareness Month activities all year round. Additional information about STDs is available at http://www.cdc.gov/std.

Reference
1.Weinstock H, Berman S, Cates W Jr. Sexually transmitted diseases among American youth: incidence and prevalence estimates, 2000. Perspect Sex Reprod Health 2004;36:6--10.


Announcements: STD Awareness Month --- April 2011

Announcements: Epidemiology in Action: Intermediate Analytic Methods Course --- May 31--June 1, 2011

Announcements: Epidemiology in Action: Intermediate Analytic Methods Course --- May 31--June 1, 2011
Weekly
April 1, 2011 / 60(12);379




Emory University's Rollins School of Public Health and CDC's Office of Surveillance, Epidemiology, and Laboratory Services will cosponsor Epidemiology in Action: Intermediate Analytic Methods, to be held May 31--June 3, 2011, at Emory University. This course is designed for public health professionals who have had training and experience in basic applied epidemiology and would like training in additional quantitative skills related to analysis and interpretation of epidemiologic data.

The course includes a review of the fundamentals of descriptive epidemiology and biostatistics, measures of association, normal and binomial distributions, confounding, statistical tests, stratification, logistic regression models, and computer programs as used in epidemiology.

The prerequisite is an introductory course in epidemiology taken as an undergraduate or graduate student or completion of courses such as Epidemiology in Action or the International Course in Applied Epidemiology. Tuition will be charged.

Additional information and applications are available from Emory University by mail (Hubert Department of Global Health [Attn: Pia], 1518 Clifton Rd. NE, Rm. 7038, Atlanta, GA 30322), by telephone (404-727-3485); by fax (404-727-4590), online (http://www.sph.emory.edu/epicourses), or by email (pvaleri@emory.edu).


Announcements: Epidemiology in Action: Intermediate Analytic Methods Course --- May 31--June 1, 2011

Announcements: Autism Awareness Month --- April 2011

Announcements: Autism Awareness Month --- April 2011
Weekly
April 1, 2011 / 60(12);379




April is Autism Awareness Month. CDC's most recent report from the 11 sites that make up the Autism and Developmental Disabilities Monitoring (ADDM) Network identified 2,757 children with autism spectrum disorders (ASDs) in a total population of 308,038 children aged 8 years, indicating a prevalence of approximately one in 110 (or 1% of children) (1). ASDs are a group of developmental disabilities characterized by atypical development in socialization, communication, and behavior. The symptoms of ASDs typically are present before age 3 years and often are accompanied by abnormalities in cognitive functioning, learning, attention, and sensory processing (1,2).

Efforts are needed to understand how complex genetic and environmental factors interact to result in the manifestations that make up the autism spectrum. In addition to differences in ASD prevalence by race/ethnicity, sex, and cognitive functioning, potential risk factors (e.g., variations by urban and rural area, sociodemographic status, perinatal complications, and parental age) also need further study. ADDM data are being analyzed to better understand the roles of these and other factors. Studies such as the Study to Explore Early Development, a CDC-funded study examining various risk factors for ASD, are being conducted and are necessary to test hypotheses more fully.

CDC also is working with caregiver and professional groups through the "Learn the Signs. Act Early" health education program to improve early identification of ASDs and other developmental disabilities (3). CDC has resources and information for health-care providers, including information on screening tools and free educational materials to give to patients. These resources are available at http://www.cdc.gov/actearly. Additional information about autism and CDC's activities is available at http://www.cdc.gov/autism.

References
1.CDC. Prevalence of autism spectrum disorders---Autism and Developmental Disabilities Monitoring Network, United States, 2006. MMWR 2009;58(No. SS-10) [Prevalence of Autism Spectrum Disorders --- Autism and Developmental Disabilities Monitoring Network, United States, 2006].
2.Yeargin-Allsopp M, Rice C, Karapurkar T, Doernberg N, Boyle C, Murphy C. Prevalence of autism in a US metropolitan area. JAMA 2003;289:49--55.
3.CDC. Learn the signs. Act early. Atlanta, GA: US Department of Health and Human Services, CDC; 2006. Available at http://www.cdc.gov/actearly. Accessed March 23, 2011.

full-text:
Announcements: Autism Awareness Month --- April 2011

Measles Outbreaks and Progress Toward Measles Preelimination --- African Region, 2009--2010

Measles Outbreaks and Progress Toward Measles Preelimination --- African Region, 2009--2010
Weekly
April 1, 2011 / 60(12);374-378




In 2008, the World Health Organization (WHO) African Region (AFR) measles technical advisory group (TAG) recommended establishing a measles preelimination goal, to be achieved by the end of 2012. The goal sets the following targets for the 46 AFR countries: ≥98% reduction in estimated regional measles mortality compared with 2000; measles incidence of <5 cases per 1 million population per year nationally; >90% national measles-containing vaccine (MCV) first dose (MCV1) coverage and >80% MCV1 coverage in all districts; and ≥95% MCV coverage by supplementary immunization activities (SIAs) in all districts (1). The goal also sets surveillance performance targets of ≥2 cases of nonmeasles febrile rash illness per 100,000 population, ≥1 suspected measles cases investigated with blood specimens in ≥80% of districts, and routine reporting from all districts (1). In addition, introduction of a routine second MCV dose (MCV2) was recommended for countries meeting specific criteria for MCV1 coverage and measles surveillance (1,2). This report updates progress toward the preelimination goal during 2009--2010 and summarizes measles outbreaks occurring in AFR countries since 2008. Of the 46 AFR countries, 12 (26%) reported measles incidence of <5 cases per 1 million population during 2010, compared with 28 (61%) in 2008. Furthermore, 28 (61%) countries reported a laboratory-confirmed measles outbreak during 2009--2010 (3). The recent measles outbreaks highlight the need for renewed dedication by donors and governments to ensure that national multiyear vaccination plans, national budgetary line items, and financial commitments exist for routine immunization services and measles control activities.

Measles Vaccination Coverage

The 46 AFR countries* report routine vaccination coverage to the WHO Regional Office for Africa (AFRO) using the WHO and United Nations Children's Fund (UNICEF) Joint Reporting Form (JRF) (4). In addition, WHO and UNICEF publish MCV1 coverage estimates based on multiple data sources, including JRF reports and demographic surveys (5). As of 2010, MCV1 was administered routinely at age 9 months† in 43 countries, and MCV2 was included in the routine immunization program in seven countries (Algeria, Cape Verde, Lesotho, Mauritius, Seychelles, South Africa, and Swaziland).

During 2001--2008, reported MCV1 coverage increased from 55% to 79% in the region (6). In 2009, AFR MCV1 administrative coverage§ was 83%, based on the most recent JRF data; the WHO and UNICEF regional MCV1 coverage estimate was 69% (Figure 1). In 2009, four (9%) countries (Burkina Faso, Gambia, Mauritius, and Sao Tome and Principe) reported >80% MCV1 coverage in all districts. To interrupt endemic transmission of measles, mathematical models indicate that 93%--95% population immunity is needed (7). Since 1997, 41 (89%) countries (all except Algeria, Cape Verde, Mauritius, Sao Tome and Principe, and Seychelles) have conducted an SIA targeting children aged 9 months--14 years, and 43 (93%) countries (all except Algeria, Mauritius, and Seychelles) have conducted at least one SIA targeting children aged 9--59 months. A nationwide SIA was conducted in 31 (67%) countries during 2009--2010 (Table); of these countries, five (16%) (Ethiopia, Ghana, Malawi, Zambia, and Zimbabwe) conducted post-SIA vaccination coverage surveys.

Measles Surveillance

Data on suspected measles cases are tallied monthly at local health facilities, reported to the district level, aggregated at the national level, and annually reported to AFRO using the JRF (8). JRF data on 2010 suspected measles cases were not yet available; thus, 2010 measles case-based surveillance data reported to AFRO by 40 (87%) countries, in accordance with WHO AFRO measles surveillance guidelines, are cited instead (8). During 2001--2008, reported measles cases in AFR decreased by 93%, and estimated measles-related mortality declined 91% (2). The number of reported measles cases decreased from 520,102 in 2000 to 37,162 in 2008, then increased to 83,464 in 2009 and to 172,824 in 2010 (Figure 1). Of 172,824 reported cases, 23,842 (14%) were laboratory confirmed and 109,570 (63%) were confirmed through epidemiologic link¶ (3). During 2010, 25 (63%) countries met the nonmeasles febrile rash illness reporting target of ≥2 cases per 100,000 population and 29 (73%) had ≥80% of districts reporting ≥1 suspected cases with blood specimen. The overall confirmed measles incidence for the region in 2010 was 17.2 per 100,000 population and 12 (30%) countries reported measles incidence of <5 cases per 1 million population (Figure 2).

During 2009 and 2010, B3 measles virus was detected in all 25 countries with genotype information and was the predominant genotype in the region. In addition to the B3 outbreak strain, Angola and Namibia reported transmission of the B2 genotype, and South Africa reported two additional genotypes: a D4 from a single case imported during the World Cup games in June 2010 and a D8 from a single case in 2009.

Major Outbreaks and Response Activities

During 2009--2010, a total of 28 (61%) of the 46 AFR countries had laboratory-confirmed measles outbreaks** with >100 reported measles cases, including 13 countries in 2009 and 15 additional countries in 2010 (Table), compared with nine (20%) countries in 2008. Of these 28 countries, 10 reported ≥90% MCV1 coverage in 2009, 15 had a follow-up SIA within 24 months before the outbreak, and all reported ≥90% SIA administrative coverage in the most recent measles SIA (Table). Of the 28 countries with reported outbreaks, 20 conducted an outbreak investigation and 14 implemented an outbreak response immunization (ORI) campaign or a nationwide SIA following the start of the outbreak.

In some AFRO countries, frequent outbreaks continued, suggesting that children were missed by routine vaccinations and by SIAs in recent years. Measles outbreaks in which the majority of cases involved children aged <5 years occurred in Angola, Democratic Republic of Congo, Ethiopia, Nigeria, and Sierra Leone. Ethiopia, for example, reported that MCV1 coverage increased from 59% in 2005 to 75% in 2009. The last nationwide measles SIA, conducted in three phases during 2007--2009, targeted children aged 9--59 months, with reported coverage of 98%, 92%, and 93%, respectively. The 2009 nonmeasles febrile rash illness rate was 2.4 per 100,000 population, and 87% of districts reported ≥1 suspected cases with blood specimen. In 2009, 1,176 suspected cases were reported, compared with 8,261 cases in 2010 in 93 of 96 administrative zones. Of the cases reported in 2010, a total of 4,182 (51%) were confirmed by either laboratory testing or epidemiologic link. Of the confirmed cases, 3,142 (75%) were among children aged <5 years, and 3,877 (93%) were among unvaccinated persons. In 2010, an ORI campaign was conducted in 54 districts of five zones, targeting children aged 6--59 months, with reported coverage >100%.

In AFRO countries with higher, but still suboptimal, MCV1 coverage and SIA implementation, the age distribution of measles cases shifted to include older children and young adults. A measles outbreak pattern in which the age distribution of measles cases included older children and young adults occurred in Burkina Faso, Malawi, Namibia, South Africa, and Zambia. In Malawi, for example, reported MCV1 coverage increased from 82% in 2005 to 92% in 2009; a nationwide SIA targeting children aged 9--59 months was implemented in both 2005 and 2008, each with >95% reported coverage. In 2009, the nonmeasles febrile rash illness rate was 3.8 per 100,000 and 96% of districts reported ≥1 suspected case with blood specimen. In 2010, 73,727 suspected measles cases were reported from 24 of 28 districts in Malawi. Among 35,366 patients reported during October 24, 2009--July 17, 2010, a total of 14,627 (41%) were aged <5 years, 11,391 (32%) were aged 5--14 years, and 9,348 (26%) were aged ≥15 years. An initial ORI campaign was conducted 3 months after the start of the outbreak in three districts targeting children aged 9--59 months. A second ORI campaign was conducted 5--6 months after the outbreak started in eight districts targeting children aged 6 months--14 years in affected schools and prisons with clusters of patients. In 2010, a nationwide SIA was implemented targeting children aged 6 months--14 years with >95% administrative coverage in 26 of 28 districts.

Reasons for nonvaccination identified through outbreak investigations during 2009--2010 included vaccine unavailability; strict adherence to the WHO open vial policy,†† leading to batching of children into infrequent vaccination sessions; and exclusion of children aged >12 months, who were considered ineligible for MCV1. In addition, unwillingness to receive vaccination was identified among certain religious groups in Zimbabwe, Botswana, Malawi, and South Africa.

Reported by
Countries in the WHO African Region; Immunization and Vaccine Development Program, WHO Regional Office for Africa. Dept of Immunization, Vaccines, and Biologicals, WHO, Geneva, Switzerland. Global Immunization Div, National Center for Immunization and Respiratory Diseases, CDC.

Editorial Note

During 2001--2008, AFR countries made remarkable progress in reducing measles mortality and morbidity by increasing MCV1 coverage and periodic SIAs (2). However, since reaching an historic low of 32,278 reported cases in 2008, a resurgence of measles led to multiple large outbreaks during 2009--2010, despite increases in reported MCV1 coverage, indicating the fragility of the progress (Figure 1). Suboptimal routine and SIA vaccination coverage led to an increasing number of susceptible persons over a prolonged period of low incidence, allowing some children to remain susceptible as they grew older. Outbreak cases occurring among older children and young adults suggest some progress in reducing measles incidence together with long-standing gaps in vaccination activities. In countries with large outbreaks occurring primarily among children aged <5 years, substantial numbers of children were missed by both routine vaccination and SIAs in recent years. In these countries, estimated MCV1 coverage remains suboptimal and reviews of vaccination services are needed to identify programmatic reasons for nonvaccination (9). Detailed outbreak investigations are recommended to describe the epidemiology of an outbreak, guide rapid ORI, and determine the likely cause of the outbreak (e.g., failure to vaccinate) (1).

The findings in this report are subject to at least two limitations. First, underreporting of measles cases and low sensitivity of measles case-based surveillance in some countries likely led to underestimates of measles incidence. Second, SIA administrative coverage >100% suggests inaccurate and inflated reported coverage (9).

Although post-SIA coverage surveys are recommended, only five of 31 countries implemented a post-SIA coverage survey during 2009--2010. Estimates of vaccination coverage from population-based coverage surveys are key inputs to determine the susceptibility profile of a population. In addition, reliable coverage estimates can help identify areas of low coverage so that program managers can better prioritize and more efficiently use resources. Even though AFR reported MCV coverage has increased continuously and the quality of measles surveillance has improved, subsequent measles outbreaks raise doubts concerning the accuracy and reliability of reported coverage and surveillance data. WHO-recommended methods for improving the accuracy of monitoring measles vaccination programs and post-SIA surveys to estimate coverage should be implemented routinely (1).

The 2009--2010 outbreaks highlight the need for full implementation of regional strategies, with an emphasis on improving vaccination coverage through routine immunization services and SIAs in every district, and introduction of MCV2 into routine immunization services in eligible countries (1). National immunization program policies and delivery systems should be reviewed to ensure access to the recommended 2 doses of MCV by all eligible children. Communication strategies should be identified to ensure vaccination acceptance and demand among all segments of the population. Renewed dedication by donors and governments is needed to ensure that national multiyear plans, budgetary line items, and financial commitments exist for routine immunization services and measles control activities.

full-text:
Measles Outbreaks and Progress Toward Measles Preelimination --- African Region, 2009--2010

CDC Grand Rounds: Chlamydia Prevention: Challenges and Strategies for Reducing Disease Burden and Sequelae

CDC Grand Rounds: Chlamydia Prevention: Challenges and Strategies for Reducing Disease Burden and Sequelae
Weekly
April 1, 2011 / 60(12);370-373

This is another in a series of occasional MMWR reports titled CDC Grand Rounds. These reports are based on grand rounds presentations at CDC on high-profile issues in public health science, practice, and policy. Information about CDC Grand Rounds is available at http://www.cdc.gov/about/grand-rounds.




Chlamydia, a sexually transmitted infection caused by the bacterium Chlamydia trachomatis, is the most commonly reported nationally notifiable disease. A total of 1,244,180 cases were reported in 2009 (1). However, many infections are not detected, and an estimated 2.8 million infections occur each year (2). The burden of infection is greatest among sexually active adolescents and young adults; chlamydia prevalence among sexually active persons aged 14--24 years is nearly three times the prevalence among those aged 25--39 years (National Health and Nutrition Examination Survey 1999--2008 [NHANES], unpublished data, 2011) (Figure 1). Substantial racial/ethnic disparities in chlamydial infection exist, with prevalence among non-Hispanic blacks approximately five times the prevalence among non-Hispanic whites. Among sexually active females aged 14--19 years, chlamydia prevalence is 6.8% overall (4.4% among non-Hispanic whites and 16.2% among non-Hispanic blacks).

The majority of genital chlamydial infections in both males and females are asymptomatic (3). When symptoms do occur, lower urogenital tract infection can manifest as cervicitis in females and urethritis in males and females. Whether symptomatic or asymptomatic, untreated chlamydia can ascend to the upper genital tract. In males, this can cause epididymitis, which is not thought to be an important cause of long-term sequelae. However, in females, upper tract infection can result in pelvic inflammatory disease (PID), a spectrum of clinical disorders involving infection and inflammation of the uterus, fallopian tubes, ovaries, or adjacent peritoneum. Both clinically diagnosed PID and subclinical upper genital tract infection can result in fibrosis, scarring, and loss of tubal function, which can in turn lead to serious long-term reproductive consequences, including tubal factor infertility (inability to conceive because of structural or functional fallopian tube damage), ectopic pregnancy, and chronic pelvic pain.

Available natural history data have limitations but suggest that 10%--15% of untreated chlamydial infections result in diagnosed clinical PID (4,5). Once clinical PID occurs, up to 10%--15% of cases might lead to tubal factor infertility (4). Chlamydia also can lead to tubal infection that is not diagnosed as PID; thus, an even greater proportion of untreated infections likely lead to infertility. Approximately 750,000 PID cases are diagnosed each year in the United States (6). However, PID has multiple infectious etiologies, and the burden of chlamydia-related PID is difficult to determine. Infertility is a major public health problem; in 2002, 7.4% of married females aged 15--44 years were infertile, and nearly one in five females aged 40--44 years reported receiving a medical service for infertility at some point (7). The proportion of all infertility that is tubal factor varies by clinical setting, ranging from 10% to 40% (8,9). Chlamydia is the leading preventable cause of tubal factor infertility (8). Direct medical costs of chlamydia, including diagnosing and treating chlamydia-associated infertility, are estimated at $701 million annually (in 2010 U.S. dollars) (3).

Prevention Challenges and Solutions

Chlamydia prevention programs have been implemented to reduce the burden of reproductive sequelae resulting from chlamydial infection. Because most reproductive complications of chlamydia occur in females and most infections are asymptomatic, the cornerstone of chlamydia prevention is screening young females for infection. Chlamydia is easily diagnosed and treated. Nucleic acid amplification tests are the preferred diagnostic tests because of their superior sensitivity, and they can be performed on easily collected specimens, such as urine or vaginal swabs. Highly efficacious treatment options include single-dose oral azithromycin or a 1-week course of doxycycline. National chlamydia screening recommendations were first released in 1993. Currently, CDC, the U.S. Preventive Services Task Force (USPSTF), and numerous professional medical associations recommend annual chlamydia screening for all sexually active females aged <25 years and for females aged ≥25 years if they are at increased risk for infection (e.g., if they have new or multiple sex partners) (10). USPSTF defines chlamydia screening of sexually active young females as an A-rated recommended preventive service (strongest recommendation), based on randomized controlled trial data demonstrating that screening reduces PID incidence (2).

Evidence is insufficient to recommend routine chlamydia screening for males because of several factors, including feasibility, impact, and cost-effectiveness in preventing sequelae in females (10). However, targeted male screening in high prevalence settings (e.g., correctional facilities) should be considered when resources permit and such screening does not hinder chlamydia screening efforts in females (10). Male partners of females infected with chlamydia have the highest prevalence of infection and should be the top priority for chlamydia testing and treatment efforts among males.

National screening recommendations have been in place for 18 years. Assessing the success of chlamydia prevention programs in reducing chlamydial infections and associated sequelae is critical. Traditionally, sexually transmitted disease (STD) trends have been monitored through case reports, and reported chlamydia case rates have climbed steadily during the past 2 decades (1). However, reported case rates do not necessarily reflect actual trends in incidence of infection. Increased case rates most likely are attributed to increased detection of infection through greater screening and use of more sensitive tests. In fact, prevalence data from several sources indicate that national chlamydia prevalence has not increased during the past decade and might actually be decreasing (11,12). For example, in a study conducted among women and men entering the National Job Training Program, the adjusted odds of a positive chlamydia test decreased by 19% in women and 8% in men during 2003--2007 (12). In addition, although PID has multiple causes, several data sources demonstrate that PID rates have been decreasing (1,6,13). After substantial declines in PID rates during the late 1980s and 1990s (6), a 25% decline in PID rates during 2001--2005 was observed using a sample of national insurance claims data (13). Overall, available ecologic evidence suggests that current chlamydia prevention programs, focused primarily on screening young females, are having some impact on chlamydia prevalence and PID, but not enough.

Screening females aged <25 years is ranked by the National Commission on Prevention Priorities as one of the 10 most beneficial and cost-effective prevention services, but it also is among the most underutilized (14). Screening coverage increased during 2001--2009 but still was less than 60%; in 2009, coverage was 43% among eligible females enrolled in commercial health-care plans and 57% among the Medicaid population (Figure 2) (15). Expanding chlamydia screening will be critical to reducing disease burden and associated reproductive sequelae. In addition, other prevention strategies also should play an important role, including behavioral interventions, rescreening of infected persons, and partner treatment efforts.

Behavioral risk reduction efforts, such as promoting correct and consistent condom use, can have an impact not only on chlamydia, but also on other STDs, including human immunodeficiency virus (HIV) infection, and on unintended pregnancy (10). Because repeat chlamydial infection is common, CDC recommends rescreening persons with chlamydia 3 months after treatment (10). Finally, treating male sex partners of infected females is critical in preventing repeat infections in females, and modeling work has shown that it also is essential in interrupting chlamydia transmission in the population (16). A safe, effective partner treatment tool endorsed by CDC and many medical associations is expedited partner therapy (EPT) (17). EPT involves providing prescriptions or medications to a patient to take to his/her partner, without examining the partner. EPT has been shown to be useful in ensuring partner treatment among males and reducing repeat infections among females (17).

Barriers exist in implementing chlamydia prevention strategies. Young females might lack knowledge about the need for screening and might be reluctant to seek STD services because of fears related to disclosing sexual activity to health-care providers and the societal stigma related to STDs. In addition, young adults (i.e., those aged 20--29 years) remain the largest uninsured group in the United States, with associated underutilization of health care (18). When young females do seek care, many health-care providers fail to take a sexual history and offer chlamydia screening. Clinicians might have limited knowledge about STDs and screening recommendations, might lack information about community STD rates, and might believe their patients are not at high risk (19). High deductibles and copayments for clinic visits, laboratory services, and medications might be another important barrier. For adolescents, maintaining confidentiality is of particular concern. All 50 states and the District of Columbia currently allow minors to seek care for STD diagnosis and treatment without parental consent; however, maintaining confidentiality in the billing and insurance claims process is challenging. Many states mandate commercial health plans to provide written statements to the primary insured, usually parents or guardians, listing services rendered and those reimbursed by the health plan. Thus, "confidential" services could potentially be disclosed.

Several initiatives are under way to expand chlamydia screening efforts. To address the stigma and the lack of information about chlamydia and other STDs, CDC and its partners, MTV Networks, the Kaiser Family Foundation, and the Planned Parenthood Federation of America, are in the third year of a national campaign known as GYT (Get Yourself Tested).* The goals are to increase awareness among adolescents and young adults, normalize conversations about STD prevention, and promote sexual health and STD testing. The campaign includes public service announcements, videos, an STD testing service locator that can be accessed via website or mobile phone, and tips on generating conversations about STD testing. The Patient Protection and Affordable Care Act of 2010 expands insurance access for young adults and eliminates chlamydia screening copayments for young females who sign up for new insurance plans.† The National Chlamydia Coalition is training medical professionals, endorsing screening by professional medical associations, developing tools to facilitate office-based screening, disseminating information through lectures, articles, and webinars, and promoting quality measures to improve the care of adolescents.§ The coalition also is working to address racial/ethnic disparities in chlamydia prevalence, for example, by using mini-grants to develop community-level prevention approaches in areas with a disproportionate burden. The American Academy of Pediatrics and the Society for Adolescent Health and Medicine have developed coding and billing tools to maximize provider reimbursement while minimizing potential disclosure of confidential services through health plan billing statements.¶

One of the primary barriers to improving partner treatment services for chlamydia has been concerns about the legality of EPT in various jurisdictions. National advocacy efforts have been successful in removing many EPT legal and health systems barriers. In 2006, EPT was legally permissible in 12 states; as of November 2010, it was permissible in 27 states and one city. California was one of the first states to legalize EPT. In monitoring chlamydia partner services, California has found the highest levels of partner treatment with EPT, as well as with an alternative partner treatment strategy, "bring your own partner" (BYOP) (Figure 3) (20). With BYOP, at the time clinic staff members contact patients regarding their positive chlamydia test results and the need for timely treatment, staff members encourage patients to bring their partners with them when they come for treatment. For all partner treatment strategies, cost remains a major barrier to implementation. Ensuring coverage of the partner's prescribed treatment is critical. Effective partner treatment is an evidence-based prevention intervention that can reduce the risk for reinfection in females and ongoing transmission of chlamydia in the population.

Summary and Next Steps

A substantial burden of chlamydia exists in the United States. Chlamydia is an important preventable cause of infertility and other adverse reproductive health outcomes. Effective prevention interventions are available to reduce the burden of chlamydia and its sequelae, but they are underutilized. Although prevention programs appear to be having some impact on chlamydia prevalence and PID, improvements can be made in raising awareness about chlamydia, increasing screening coverage, and enhancing partner services, including EPT. In addition, efforts should focus on reaching disproportionately affected racial/ethnic groups. Improving measurement of program implementation and outcomes also is critical. Chlamydia prevention presents many challenges but also opportunities for improvement. To break the cycle of chlamydia transmission in the United States, health-care providers should encourage annual chlamydia screening for all sexually active females aged <25 years, maximize use of effective partner treatment services, and rescreen infected females and males 3 months after treatment.

Reported by
CL Satterwhite, MSPH, MPH, SL Gottlieb, MD, R Romaguera, DMD, Div of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC. G Bolan, MD, Center of Infectious Diseases, California Dept of Public Health. G Burstein, MD, Dept of Pediatrics, Univ at Buffalo; Women and Children's Hospital of Buffalo, Buffalo, New York. C Schuler, PhD, Div of Respiratory Disease Studies, National Institute of Occupational Health; T Popovic, MD, PhD,* Office of the Director, CDC. *Corresponding contributor: Tanja Popovic, Office of the Director, CDC, 404-639-7220, tpopovic@cdc.gov.


full-text:
CDC Grand Rounds: Chlamydia Prevention: Challenges and Strategies for Reducing Disease Burden and Sequelae

Tetanus Surveillance --- United States, 2001--2008

Tetanus Surveillance --- United States, 2001--2008
Weekly
April 1, 2011 / 60(12);365-369




Tetanus is a life-threatening but preventable disease caused by the toxin of Clostridium tetani, a ubiquitous, spore-forming, gram-positive bacillus found in high concentrations in soil and animal excrement. Reported tetanus cases have declined >95%, and deaths from tetanus have declined >99% in the United States since 1947, when the disease became reportable nationally. To update a previous report (1) and to determine the populations at greatest risk for the disease, CDC analyzed cases reported to the National Notifiable Diseases Surveillance System (NNDSS) during 2001--2008. This report summarizes the results of that analysis, which found that 233 tetanus cases were reported during 2001--2008; among the 197 cases with known outcomes, the case-fatality rate was 13.2%. Average annual incidence during that period was 0.10 per 1 million population overall and 0.23 among persons aged ≥65 years. Incidence among Hispanics was nearly twice that among non-Hispanics, a difference accounted for by 16 cases among Hispanic injection drug users (IDUs). Among the 92 patients for whom tetanus toxoid-containing (TT) vaccination status was available, 37 (40.2%) had received no doses of TT vaccine. Thirty (15.4%) of 195 patients had diabetes, and 27 (15.3%) of 176 were IDUs. Of 51 patients with an acute wound and a surveillance report complete enough to evaluate tetanus prophylaxis, 49 (96.1%) had not received appropriate prophylaxis. Tetanus remains a rare but life-threatening disease in the United States. Health-care providers should ensure up-to-date TT vaccination of all their patients, especially persons aged ≥65 years, persons with diabetes, and injection drug users.

From 1947 to 2008, the number of tetanus cases reported each year, which already had decreased greatly since 1900, continued to decline (Figure), in part because of continued use of tetanus antitoxin for wound management and introduction of TT vaccines in the 1930s and 1940s, which led to universal childhood immunization and the addition of decennial TT boosters for adults (2,3). A major contributor to the decline in morbidity was the near elimination of neonatal tetanus, a result attributable to improved childbirth practices and to increased levels of maternal immunity resulting from universal childhood vaccination (1). Sporadic cases of tetanus continue to occur in adults, especially in persons who were not vaccinated in childhood; during 1998--2000, a tetanus cluster was reported among IDUs in California (1). National surveillance for tetanus is conducted to monitor trends in incidence and identify populations at increased risk.

NNDSS is a passive surveillance system that relies on physicians to report cases of tetanus to state and local health departments. Because no laboratory test provides definitive confirmation of tetanus, the diagnosis is based on the clinical judgment of attending physicians and the exclusion of other causes of disease. For reporting cases to NNDSS, health-care providers use the following definition adopted by the Council of State and Territorial Epidemiologists and CDC in 1990: a confirmed case is an acute onset of hypertonia and/or painful muscular contractions (usually of the muscles of the jaw and neck) and generalized muscle spasms without other apparent medical cause, as reported by a health professional.

Tetanus case reports, including supplemental information (e.g., clinical history, patient vaccination status, wound care, clinical management, and outcome) and epidemiologic information are verified by health departments and transmitted electronically to CDC. Vaccination histories of patients are not validated by CDC. Tetanus rates by age and race/ethnicity were calculated using mid-year postcensal population estimates for the years 2001--2008. Risk factors for death resulting from tetanus were assessed by univariate analyses followed by multivariate modeling.

During 2001--2008, a total of 233 cases were reported from 45 states; 26 (13.2%) of 197 cases for which outcome was reported were fatal. A total of 120 cases (51.5%) were reported from five states: California (60), Florida (25), Texas (12), New York (12), and Pennsylvania (11). An average of 29 cases was reported each year (range: 19--40). The average annual incidence was 0.10 per 1 million population (Table 1) and showed a slightly declining trend (Figure).

Sex and age were reported for all 233 cases. A total of 138 (59.2%) patients were male; median age was 49 years (range: 5--94 years), excluding one nonfatal neonatal case.* Average annual incidence was higher among those aged ≥65 years (0.23 cases per 1 million population) than among those aged 5--64 years (0.08 per 1 million population) (Table 1). Data on race were available for 179 (76.8%) cases; incidence was similar by race: white (0.08 per 1 million population), black (0.07), American Indian/Alaska Native (0.09), Asian/Pacific Islander (0.07), and other race (0.02). Data on Hispanic ethnicity were available for 185 (79.4%) cases. The incidence among Hispanics was almost twice that among non-Hispanics (0.13 versus 0.07 cases per 1 million population); however, when IDUs were excluded, the incidence was almost the same among Hispanics (0.08) compared with non-Hispanics (0.07).

TT vaccination status was reported for 92 (39.5%) of the 233 patients. A total of 37 patients (40.7%) received no TT doses, 26 (28.3%) received 1 dose, five (5.4%) received 3 doses, and 24 (26.1%) received ≥4 doses (Table 2). Among the 36 patients aged ≥50 years, five (13.9%) reported completing the primary 3-dose TT series, compared with 24 (42.9%) of the 56 aged <50 years. Seven (24.1%) of 29 patients with ≥3 doses of TT had received their last dose within 10 years, 18 (62.1%) from 10 to 54 years previously, and four (13.8%) reported an unknown interval since their last dose. Among 195 patients whose medical history was known, 30 (15.4%) were reported to have diabetes. Twenty-seven (15.3%) of 176 patients whose status was known were IDUs, of whom 16 (59.3%) were Hispanic. Three (11.1%) of 27 patients with diabetes and known drug use status were IDUs. An acute wound preceded disease onset in 167 (71.7%) patients. Of those patient wounds, 132 (79.0%) were punctures, or contaminated, infected, or devitalized wounds considered tetanus-prone and eligible to receive tetanus immune globulin (TIG) (4). Sixty-one (36.5%) of the 167 patients with acute wounds sought medical care. Case reports for 51 (83.6%) of those who sought care were sufficiently complete to evaluate prophylaxis received; 49 (96.1%) did not receive appropriate TT prophylaxis or TT plus TIG as is currently recommended (4). Among all 233 patients, 31 (13.3%) reported a chronic wound or infection before disease onset, including diabetic ulcers and dental abscesses. Twenty-two (9.4%) reported no wounds or infections; of these, 14 were IDUs. Among all persons with reported tetanus, the risk for fatal disease was greater among those aged ≥65 years than those aged <65 years (relative risk [RR] = 5.1; 95% confidence interval [CI] = 2.1--12.2), among those with diabetes than those without diabetes (RR = 2.4; CI = 1.2--4.8), and among those with no TT vaccination compared with those with ≥1 doses of TT (RR = 4.0; CI = 1.2--14.1). However, in the multivariable model, comparing age ≥65 years versus <65 years, diabetes versus no diabetes, and no doses of vaccination versus 1 dose, neither diabetes (odds ratio [OR] = 1.3; CI = 0.2--7.2) nor vaccination (OR = 3.1; CI = 0.7--15.1) were statistically significant. Age ≥65 years remained a factor for greater risk for fatal tetanus (OR = 9.6 ; CI = 3.6--25.0) in a final parsimonious model including only age. Sex, injection drug use, Hispanic ethnicity, unknown vaccination history, and acute injuries (versus chronic wounds) were not associated with increased risk for fatal disease in either univariate or multivariable analyses. Reported by
T Tiwari, MD,* TA Clark, MD, NE Messonnier, MD, Div of Bacterial Diseases, National Center for Immunization and Respiratory Diseases; CG Thomas, DVM, EIS Officer, CDC. *Corresponding contributor: Tejpratap Tiwari, Div of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, CDC, 404-639-8765, ttiwari@cdc.gov.


Editorial Note

Inadequate TT vaccination and inadequate wound prophylaxis remain the most important factors associated with tetanus. The findings in this report indicate that older adults are at greater risk for tetanus than younger persons, and the risk for fatal disease is higher among patients aged ≥65 years. This increased risk likely results from inadequate vaccination rather than inadequate response to vaccination, because tetanus toxoid is sufficiently immunogenic in older adults (5). In this analysis, only one patient aged ≥50 years reported having received a complete primary series and up-to-date boosters. Surveys of adults have shown declining TT vaccination coverage with increasing age, with coverage of <50% observed among persons aged ≥65 years in 2007 (6). Missed opportunities to vaccinate adult women and older adults in primary-care settings are common (7,8). Providers should review vaccination status during adult health-care visits to ensure that persons with inadequate vaccination complete the primary tetanus series and are up-to-date with booster doses. In this analysis, approximately one third of patients with acute wounds sought medical care, and among those who sought care and had sufficient case data, fewer than 4% received appropriate TT prophylaxis or TT plus TIG as recommended (4). Patients might not receive optimal tetanus prophylaxis as part of wound management because of the trivial appearance of many wounds and the failure of health-care providers to obtain a vaccination history, particularly from those who are not up to date with their TT vaccination (9). Populations considered at increased risk for tetanus include persons with tetanus-prone wounds, IDUs, and those with diabetes and chronic wounds. The prevalence of diabetes among patients in this analysis was 15%, nearly three times the average estimated prevalence of diabetes in the United States during 2001--2008 (10). Although the mechanism for increased risk is unclear, one possible explanation is that health-care providers might not suspect tetanus early in persons with chronic wounds and diabetes; approximately 13% of tetanus patients reported a chronic wound or infection before onset. Health-care providers should incorporate up-to-date decennial TT vaccination into routine diabetes management to prevent tetanus (6). Of those who reported no wound or infections, the majority were IDUs. The mechanism for the greater tetanus risk among IDUs likely is introduction of tetanus spores through contaminated heroin or injection needles. During 2001--2008, 71.7% of tetanus patients had acute wounds, but only 36.5% sought immediate medical care, thus limiting the effectiveness of secondary prevention strategies. This finding was nearly identical to that of a previous report for the period 1982--2000 (1). These data also support previous studies indicating that provision of prophylaxis is not always optimal, at least in part because tetanus can result from seemingly trivial wounds that would not trigger suspicion of tetanus risk; clinical determination of tetanus-prone wounds is not exact (4,9). In addition, this report indicates that, during 2001--2008, 13% of patients reported experiencing chronic wounds or conditions that were considered the source of tetanus infection. Many of these were not considered classic tetanus-prone wounds, according to treatment guidelines. The findings in this report are subject to at least two limitations. First, surveillance for tetanus is passive and likely to be limited by underreporting and potential misclassification of disease. Second, because not all tetanus case reports were complete, missing data regarding outcome, risk factors, and other patient characteristics might affect the accuracy of the case-fatality ratio and certain other calculations. Because C. tetani is ubiquitous in the environment, thorough assessment and management of wounds are especially important to the prevention of tetanus. Health-care providers should assess their patients' TT vaccination status with particular emphasis on up-to-date vaccination, especially if the patients are older adults, IDUs, persons with diabetes, and persons with chronic wounds. Acknowledgments
This report is based, in part, on contributions by T Pondo, MS, CE Rose Jr, PhD, Div of Bacterial Diseases, K Brown, MPH, Global Immunization Div, National Center for Immunization and Respiratory Diseases; P Srivastava , MS, Office of the Director, Office of Infectious Diseases; S Shah, MS, Div of HIV/AIDS Prevention Surveillance and Epidemiology, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, CDC.

full-text:
Tetanus Surveillance --- United States, 2001--2008