Dixie E. Snider

Multidrug-resistant Tuberculosis

Excerpt As recently as 10 years ago, tuberculosis was rapidly disappearing from the United States. Reported cases of tuberculosis were decreasing an average of almost 6% each year, from over 84 000...

Tuberculosis atypical mycobacteriosis and the acquired immunodeficiency syndrome among Haitian and non-Haitian patients in South Florida.

To study the association between mycobacterial disease and the acquired immunodeficiency syndrome, we reviewed the records of all cases of tuberculosis and all cases of the syndrome reported in Dade County, Florida, from January 1980 through June 1983. Tuberculosis was diagnosed in 27 of 45 Haitians with the syndrome, but in only 1 of 37 non-Haitians with the syndrome (p less than 0.001). Among the 27 Haitians with the syndrome and tuberculosis, 19 had extrapulmonary tuberculosis, whereas among 286 Haitian patients with tuberculosis without the syndrome, only 56 had extrapulmonary tuberculosis (p less than 0.001). Tuberculosis preceded the syndrome by 1 to 17 months (mean, 6) in 22 patients. In 10 patients with the syndrome and positive sputum cultures who were treated with conventional antituberculosis drugs, the cultures became negative within 1 to 4 months and tuberculosis did not recur. The frequency of disseminated atypical mycobacteriosis or positive sputum cultures for atypical mycobacteria was not significantly different between Haitian (11.3%) and non-Haitian (8.3%) patients with the syndrome.

The New Tuberculosis

Events during the past decade have dramatically changed the nature and magnitude of the problem of tuberculosis. Much of what many physicians learned in training about this disease is no longer tru...

Pyridoxine supplementation during isoniazid therapy

Vitamin B6 (pyridoxine) supplementation during isoniazid (INH) therapy is necessary in some patients to prevent the development of peripheral neuropathy. In vivo pyridoxine is converted into coenzymes which play an essential role in the metabolism of protein, carbohydrates, fatty acids, and several other substances, including brain amines, INH apparently competitively inhibits the action of pyridoxine in these metabolic functions. The reported frequency of INH-induced neuropathy in various studies is reviewed and population groups at relatively high risk of developing this complication are identified. The routine use of pyridoxine supplementation to prevent peripheral neuropathy in high risk populations is recommended.

The Prevalence of Tuberculosis and Drug Resistance among Haitians

TUBERCULOSIS is a major health problem among Haitians who have recently entered southern Florida. Among those medically screened on arrival, we found that the prevalence of tuberculosis was 650 cas...

Immunization policy development in the United States: the role of the Advisory Committee on Immunization Practices.

In the United States, development of immunization policy is accomplished through interactions among federal and state government agencies, professional medical societies, and other organizations. This coordinated effort results in development and implementation of immunization recommendations for infants, children, adolescents, and adults. Role of the Advisory Committee on Immunization Practices Recommendations for routine use of vaccines in adults are issued by the Centers for Disease Control and Prevention (CDC) and are harmonized to the greatest extent possible with recommendations made by the American College of Gynecologists and Obstetricians, the American Academy of Family Physicians, and the American College of Physicians. The Advisory Committee on Immunization Practices (ACIP), established in 1964 by the Surgeon General of the U.S. Public Health Service, is chartered as a federal advisory committee to provide expert external advice and guidance to the Director of the CDC and the Secretary of the U.S. Department of Health and Human Services (DHHS) on use of vaccines in the civilian population (13). The ACIP makes policy recommendations for vaccines and related agents that are licensed by the U.S. Food and Drug Administration (FDA) for prevention of diseases; guidance for use of unlicensed vaccines may be developed if circumstances warrant it (Figure). Figure. Development and dissemination of vaccine recommendations and policies. In parallel to the process followed by the American College of Physicians, the Committee on Infectious Diseases of the American Academy of Pediatrics makes recommendations to the American Academy of Pediatrics Board of Directors on immunization recommendations for infants, children, and adolescents. Harmonization of recommendations with the Advisory Committee on Immunization Practices (CDC) is optimized at several levels, including annual publication of the joint Recommended Immunization Schedule for Persons 0 Through 18 Years of Age. ACP = American College of Physicians; CDC = Centers for Disease Control and Prevention; FDA = U.S. Food and Drug Administration; MMWR = Morbidity and Mortality Weekly Report. In recent years, the number of vaccines licensed for routine use in the United States has increased, and the role of the ACIP in development of national immunization policy has become more visible (Table 1). This article describes the structure and function of the ACIP, outlines the process by which ACIP members develop and vote on immunization recommendations, and reviews how these recommendations apply to adult populations. Table 1. Licensed Vaccines in Routine Use in the United States, 1980 and 2008 Structure of the ACIP The ACIP consists of 15 voting members: a chair, a consumer representative, and 13 members with expertise in specific disciplines. Membership selection criteria include expertise in vaccinology; immunology; pediatrics; internal medicine; infectious diseases; preventive medicine; public health; or, in the case of the consumer representative, consumer perspectives or social and community aspects of immunization programs. Members, who must be U.S. citizens and cannot be employed by the U.S. government, are appointed to 4-year, overlapping terms by the Secretary of the DHHS. Efforts are made to ensure that the voting membership is balanced on the basis of geography, race and ethnicity, sex, and such other relevant factors as expertise. In addition to the 15 voting members, the Committee includes 8 ex officio members representing federal agencies and 26 nonvoting representatives of liaison organizations with broad responsibilities for vaccine development, administration of vaccines to various segments of the population, and operation of immunization programs (Table 2). Appointment of liaison organizations is approved by the Secretary of the DHHS. Individuals and liaison organizations may apply for membership directly, but they are encouraged to submit applications to the ACIP Executive Secretary according to procedures detailed on the ACIP Web site (www.cdc.gov/vaccines/recs/acip/). A formal process of review is performed by the ACIP Steering Committee, which comprises members of CDC divisions working in vaccine-related areas, a representative of the FDA, and the ACIP Chair. Recommendations for nominees (2 candidates for each vacant position) are forwarded to the CDC Director for review and are then forwarded with supporting documents to the Secretary of the DHHS, who makes the final selection of ACIP members. The complete membership roster is available on the ACIP Web site. Table 2. Ex Officio Members and Liaison Organizations of the Advisory Committee on Immunization Practices Conflicts of Interest Given the substantial financial implications that ACIP recommendations may have for the public and private sectors, as well as for vaccine manufacturers, candidates who are nominated for ACIP membership undergo careful screening for potential conflicts of interest before their names are submitted for final consideration. To ensure integrity of the ACIP, all nominees are reviewed by the ACIP Steering Committee. Stringent measures are taken to assure that there is not only technical compliance with ethics statutes and regulations regarding financial conflicts but also that more general concerns regarding potential for appearance of a conflict of interest are addressed or avoided altogether through both pre- and postappointment considerations. People with specific vaccine-related interests at the time of application are not considered for appointment to the Committee. Examples of such interests include direct employment of the candidate or an immediate family member by a vaccine manufacturer or its parent company, serving on a board of a vaccine manufacturer, and holding a patent on a vaccine or related product. Potential ACIP members are asked before submission of their names for final selection to recuse themselves during the term of membership from activities that are, or could be construed as, conflicts of interest. These activities include provision of advisory or consulting services to a vaccine manufacturer or its parent company and acceptance of honoraria or travel reimbursement from a vaccine manufacturer. Once accepted for membership, ACIP members are required every year to file confidential financial reports with the Office of Government Ethics and to disclose publicly all vaccine-related interests and work, including participation in clinical trials, at each meeting. If, despite all these safeguards, a conflict exists, limited waivers allow members to participate in committee discussions with the condition that they are prohibited from voting on matters involving the specific or competing vaccine manufacturers. A member who develops an important conflict of interest during the 4-year term will be required to resign from the ACIP. Screening for conflicts of interest is rigorous and balances the possibility of bias caused by a conflict with the need for vaccine and immunization expertise, including cross-cutting knowledge and experience in the various components of the immunization field. Some data important to the committee can be obtained only through working relationships with vaccine manufacturers. Representatives of vaccine manufacturers may present data on vaccine immunogenicity, effectiveness, and safety to ACIP workgroups and at meetings of the full ACIP, but they are not permitted to serve as members of workgroups, or have any input into ACIP deliberations. Process for Development of Recommendations Workgroups Committee workgroups are formed as a resource for gathering, analyzing, and preparing information for presentation to the Committee. Workgroups must be chaired by an ACIP member and must include at least 2 ACIP members and a CDC subject-matter expert. Other workgroup members include relevant ex officio members, liaison representatives, members of academia, and invited consultants as required. Vaccine manufacturer representatives may not serve as workgroup members. Workgroups meet throughout the year to do in-depth reviews of vaccine-related data and to develop options for policy recommendations for presentation to the Committee. Four ACIP workgroups are permanent, and the remaining workgroups, which typically focus on 1 vaccine or a group of vaccines, are established and then disbanded as appropriate (Table 3). All workgroup findings and options are presented to the ACIP in an open meeting, and this information is deliberated until members reach a majority decision. A recommendation, when voted on and approved by a majority of voting ACIP members, includes guidance on target groups for immunization, route of administration and dosing intervals, and precautions and contraindications. Table 3. Advisory Committee on Immunization Practices Workgroups To formulate policy recommendations, the ACIP reviews many factors, including morbidity and mortality associated with the disease in the general U.S. population and in specific risk groups; available scientific literature (both published and unpublished) on the safety, efficacy, effectiveness, cost-effectiveness, and acceptability of the immunizing agent, with consideration of the relevant quality and quantity of published and unpublished data; clinical trial results and use information provided in the manufacturers labeling or package insert; recommendations of other professional liaison organizations; and the feasibility of incorporating the vaccine into existing domestic immunization programs. Recommendations of the ACIP may be developed and issued jointly with nongovernmental professional organizations or other public health service advisory committees. Examples of joint recommendations include the Adult Immunization Schedule (issued jointly by the American College of Physicians, American Academy of Family Physicians, American College of Obstetricians and Gynecologists, and CDC) and Immunization

Prostaglandins and Asthma

Excerpt The prostaglandins are 20-carbon, aliphatic, monocarboxylic acids with a five-membered ring and one or more unsaturated double bonds. They are found throughout the plant and animal kingdom ...

Recurrent tuberculosis: why do patients develop disease again? A United States Public Health Service cooperative survey.

In October 1983, a retrospective survey was initiated to determine if patients reported to the Centers for Disease Control as having recurrent tuberculosis truly had recurrent disease and, if so, why they had developed tuberculosis again. Twenty-three health jurisdictions provided information on 800 patients diagnosed as having recurrent tuberculosis during 1981 and 1982. We found that 199 (25 per cent) of the cases did not meet the criteria for recurrent disease. Of the remaining 601 recurrent cases, 20 per cent had no chemotherapy prescribed for their previous episodes of tuberculosis, 20 per cent were prescribed inadequate or inappropriate therapy, and 33 per cent were not compliant with their prescribed therapy regimens. Patients who, during their original episode of tuberculosis, received the major portion of their medical care from physicians in private practice were more compliant than those treated by other health care providers. However, those same patients were more likely to have received inappropriate therapy than patients treated by other providers. Better patient and physician education, closer monitoring, and greater use of preventive therapy and directly observed therapy are necessary to resolve these problems.

BEHAVIORAL AND SOCIAL SCIENCES AT THE CENTERS FOR DISEASE CONTROL AND PREVENTION: CRITICAL DISCIPLINES FOR PUBLIC HEALTH

The mission of the Centers for Disease Control and Prevention (CDC) is to promote health and quality of life by preventing and controlling disease, injury, and disability. Fifty years ago, CDCs efforts were focused on epidemiologic and laboratory studies of malaria, typhus, and plague. Today, CDCs activities cover a broad range of diseases and conditions, and a broader range of disciplines are required to address these diverse public health problems. The behavioral and social sciences have a critical role to play in helping the public understand risk group characteristics and the frequency, context, and determinants of risky behaviors and in developing, implementing, and assessing prevention programs. CDC is taking steps to foster an environment in which behavioral and social sciences can flourish and to integrate these sciences into all of CDCs prevention activities. Other articles in this section describe the breath and nature of the contributions of behavioral and social sciences at CDC.

Isoniazid-Related Hepatotoxicity

Excerpt To the editor: The letter from Drs. Moulding, Iseman, and Sbarbaro (Ann Intern Med85:398-399, 1976) contains some misinformation concerning Public Health Service data on isoniazid-related h...