Denise Napoli

WASHINGTON — Publication bias creates a skewed picture of the true prevalence of restaurant-associated food-borne disease outbreaks in the United States, and this can lead to misdiagnosis, said Dr. Tim F. Jones, state epidemiologist for the Tennessee Department of Health.

“Ten percent of the people who came in to see their doctor for diarrhea got antibiotics. About 4% of them are cultured. And of course it's only a minuscule proportion of people who get cultured [in whom we] ever find a pathogen. So there are a ton of people out there getting unnecessary antibiotics,” he added.

At the jointly held annual Interscience Conference on Antimicrobial Agents and Chemotherapy and the annual meeting of the Infectious Diseases Society of America, Dr. Jones presented data on a search of restaurant-associated outbreaks appearing in the medical literature from 1973 to the present. An “outbreak” was defined as a minimum of two cases of similar illness and common exposure.

Dr. Jones then compared the literature search results with outbreaks reported from 1998 through 2006 via the Center for Disease Control and Prevention's Electronic Foodborne Reporting System, or EFORS. State health departments are required to report all food-borne outbreaks to the CDC using this system.

A total of 133 published restaurant-associated outbreaks were found, compared with 7,300 unpublished reports in the EFORS.

Some stark differences emerged between the groups of published and unpublished reports. Of the 133 published reports, 121, or 91%, had an etiology identified vs. only 55% of unpublished reports. Also, the median number of persons reported ill in published studies was 72 vs. 5 in unpublished reports, Dr. Jones said.

Botulism outbreaks accounted for 5% of published outbreaks, compared with 0.05% of all of those reported. Hepatitis A was identified as the etiology in 15% of published outbreaks vs. 3% of unpublished outbreaks with known etiology. And Norovirus, “far and away” the most common cause of outbreaks with a known etiology, was cited as the cause of an outbreak in 14% of published reports vs. 26% of the unpublished outbreaks.

Thus, publication bias can undermine physicians' ability to interpret the publicly available data on food-borne disease, he said. Novel pathogens or unusual circumstances surrounding the outbreak are obviously more likely to be published, Dr. Jones said. But the fear of negative publicity may also inhibit publication, especially when an outbreak is related to an infected food worker.

Among published outbreaks, one-third implicated food workers as a cause, compared with only 11% in unpublished outbreaks, Dr. Jones noted. When restricting the analysis to outbreaks with an identified etiology, the results were similar, with food workers implicated twice as often in published vs. unpublished studies.

Each year in the United States, approximately 76 million food-borne illnesses result in 5,000 deaths. From 1998 to 2006, a mean of about 1,250 outbreaks were reported annually, of which two-thirds were associated with food-preparing restaurants or delicatessens, Dr. Jones added.

WASHINGTON — Publication bias creates a skewed picture of the true prevalence of restaurant-associated food-borne disease outbreaks in the United States, and this can lead to misdiagnosis, said Dr. Tim F. Jones, state epidemiologist for the Tennessee Department of Health.

“Ten percent of the people who came in to see their doctor for diarrhea got antibiotics. About 4% of them are cultured. And of course it's only a minuscule proportion of people who get cultured [in whom we] ever find a pathogen. So there are a ton of people out there getting unnecessary antibiotics,” he added.

At the jointly held annual Interscience Conference on Antimicrobial Agents and Chemotherapy and the annual meeting of the Infectious Diseases Society of America, Dr. Jones presented data on a search of restaurant-associated outbreaks appearing in the medical literature from 1973 to the present. An “outbreak” was defined as a minimum of two cases of similar illness and common exposure.

Dr. Jones then compared the literature search results with outbreaks reported from 1998 through 2006 via the Center for Disease Control and Prevention's Electronic Foodborne Reporting System, or EFORS. State health departments are required to report all food-borne outbreaks to the CDC using this system.

A total of 133 published restaurant-associated outbreaks were found, compared with 7,300 unpublished reports in the EFORS.

Some stark differences emerged between the groups of published and unpublished reports. Of the 133 published reports, 121, or 91%, had an etiology identified vs. only 55% of unpublished reports. Also, the median number of persons reported ill in published studies was 72 vs. 5 in unpublished reports, Dr. Jones said.

Botulism outbreaks accounted for 5% of published outbreaks, compared with 0.05% of all of those reported. Hepatitis A was identified as the etiology in 15% of published outbreaks vs. 3% of unpublished outbreaks with known etiology. And Norovirus, “far and away” the most common cause of outbreaks with a known etiology, was cited as the cause of an outbreak in 14% of published reports vs. 26% of the unpublished outbreaks.

Thus, publication bias can undermine physicians' ability to interpret the publicly available data on food-borne disease, he said. Novel pathogens or unusual circumstances surrounding the outbreak are obviously more likely to be published, Dr. Jones said. But the fear of negative publicity may also inhibit publication, especially when an outbreak is related to an infected food worker.

Among published outbreaks, one-third implicated food workers as a cause, compared with only 11% in unpublished outbreaks, Dr. Jones noted. When restricting the analysis to outbreaks with an identified etiology, the results were similar, with food workers implicated twice as often in published vs. unpublished studies.

Each year in the United States, approximately 76 million food-borne illnesses result in 5,000 deaths. From 1998 to 2006, a mean of about 1,250 outbreaks were reported annually, of which two-thirds were associated with food-preparing restaurants or delicatessens, Dr. Jones added.

WASHINGTON — Publication bias creates a skewed picture of the true prevalence of restaurant-associated food-borne disease outbreaks in the United States, and this can lead to misdiagnosis, said Dr. Tim F. Jones, state epidemiologist for the Tennessee Department of Health.

“Ten percent of the people who came in to see their doctor for diarrhea got antibiotics. About 4% of them are cultured. And of course it's only a minuscule proportion of people who get cultured [in whom we] ever find a pathogen. So there are a ton of people out there getting unnecessary antibiotics,” he added.

At the jointly held annual Interscience Conference on Antimicrobial Agents and Chemotherapy and the annual meeting of the Infectious Diseases Society of America, Dr. Jones presented data on a search of restaurant-associated outbreaks appearing in the medical literature from 1973 to the present. An “outbreak” was defined as a minimum of two cases of similar illness and common exposure.

Dr. Jones then compared the literature search results with outbreaks reported from 1998 through 2006 via the Center for Disease Control and Prevention's Electronic Foodborne Reporting System, or EFORS. State health departments are required to report all food-borne outbreaks to the CDC using this system.

A total of 133 published restaurant-associated outbreaks were found, compared with 7,300 unpublished reports in the EFORS.

Some stark differences emerged between the groups of published and unpublished reports. Of the 133 published reports, 121, or 91%, had an etiology identified vs. only 55% of unpublished reports. Also, the median number of persons reported ill in published studies was 72 vs. 5 in unpublished reports, Dr. Jones said.

Botulism outbreaks accounted for 5% of published outbreaks, compared with 0.05% of all of those reported. Hepatitis A was identified as the etiology in 15% of published outbreaks vs. 3% of unpublished outbreaks with known etiology. And Norovirus, “far and away” the most common cause of outbreaks with a known etiology, was cited as the cause of an outbreak in 14% of published reports vs. 26% of the unpublished outbreaks.

Thus, publication bias can undermine physicians' ability to interpret the publicly available data on food-borne disease, he said. Novel pathogens or unusual circumstances surrounding the outbreak are obviously more likely to be published, Dr. Jones said. But the fear of negative publicity may also inhibit publication, especially when an outbreak is related to an infected food worker.

Among published outbreaks, one-third implicated food workers as a cause, compared with only 11% in unpublished outbreaks, Dr. Jones noted. When restricting the analysis to outbreaks with an identified etiology, the results were similar, with food workers implicated twice as often in published vs. unpublished studies.

Each year in the United States, approximately 76 million food-borne illnesses result in 5,000 deaths. From 1998 to 2006, a mean of about 1,250 outbreaks were reported annually, of which two-thirds were associated with food-preparing restaurants or delicatessens, Dr. Jones added.

WASHINGTON — Probiotic yogurt did not prevent antibiotic-associated diarrhea in a randomized, double-blind trial of about 300 adult patients.

According to the study authors, meta-analyses have suggested that probiotics may be helpful for antibiotic-associated diarrhea, but few large, randomized, controlled trials have been conducted.

A 2007 study did find that probiotics helped prevent antibiotic-associated diarrhea, but the study was fairly small (Can. J. Gastroenterol. 2007;21:732–6).

In the current study, Dr. Alberto Delgado-Iribarren of the microbiology department at the Hospital Universitario Fundación Alcorcón, Madrid, and his colleagues studied more than 300 patients who were admitted to the hospital and started on an antibiotic regimen of either levofloxacin or amoxicillin clavulanate. The mean age of the patients was 76 years; 46% were women.

In all, 122 patients were randomized to receive placebo yogurt (which contained Streptococcus thermophilus and Lactobacillus bulgaricus but no probiotics), another 125 patients were given a probiotic yogurt mixture specially manufactured for the study (which included both S. thermophilus and L. bulgaricus, as well as L. acidophilus, Bifidobacterium lactis, and L. casei), and 65 patients were randomized to receive no yogurt. The yogurt was given in doses of 150–200 mL. Both yogurts had the same taste, color, smell, and texture.

Patients consumed the yogurt from the beginning of antibiotic treatment to 5 days after discontinuing the antibiotic, and the follow-up period was 1 month.

The patients answered a questionnaire about diarrhea and side effects. Diarrhea was defined as two or more soft stools. Secondary end points included number of days of diarrhea, severity of diarrhea, number of stools per day, and longer hospital stay because of diarrhea.

In his presentation at the jointly held annual Interscience Conference on Antimicrobial Agents and Chemotherapy and the annual meeting of the Infectious Diseases Society of America, Dr. Delgado-Iribarren reported that “our data were essentially identical for all three groups,” with “a similar proportion of around 20% of patients with diarrhea” and no statistically significant differences among the three groups.

The secondary end points were also mostly similar. Duration of diarrhea was about 3 days, with a maximum of about five stools per day. Controls had a slightly longer average hospital stay than did patients who took the probiotic yogurt.“There were no differences in mortality in the three groups,” he noted.

“We conclude that probiotic yogurt does not have an effect on … antibiotic-associated diarrhea in adults,” Dr. Delgado-Iribarren said. It is, however, safe, he added.

Dr. Delgado-Iribarren did not disclose any conflicts of interest.

WASHINGTON — Probiotic yogurt did not prevent antibiotic-associated diarrhea in a randomized, double-blind trial of about 300 adult patients.

According to the study authors, meta-analyses have suggested that probiotics may be helpful for antibiotic-associated diarrhea, but few large, randomized, controlled trials have been conducted.

A 2007 study did find that probiotics helped prevent antibiotic-associated diarrhea, but the study was fairly small (Can. J. Gastroenterol. 2007;21:732–6).

In the current study, Dr. Alberto Delgado-Iribarren of the microbiology department at the Hospital Universitario Fundación Alcorcón, Madrid, and his colleagues studied more than 300 patients who were admitted to the hospital and started on an antibiotic regimen of either levofloxacin or amoxicillin clavulanate. The mean age of the patients was 76 years; 46% were women.

In all, 122 patients were randomized to receive placebo yogurt (which contained Streptococcus thermophilus and Lactobacillus bulgaricus but no probiotics), another 125 patients were given a probiotic yogurt mixture specially manufactured for the study (which included both S. thermophilus and L. bulgaricus, as well as L. acidophilus, Bifidobacterium lactis, and L. casei), and 65 patients were randomized to receive no yogurt. The yogurt was given in doses of 150–200 mL. Both yogurts had the same taste, color, smell, and texture.

Patients consumed the yogurt from the beginning of antibiotic treatment to 5 days after discontinuing the antibiotic, and the follow-up period was 1 month.

The patients answered a questionnaire about diarrhea and side effects. Diarrhea was defined as two or more soft stools. Secondary end points included number of days of diarrhea, severity of diarrhea, number of stools per day, and longer hospital stay because of diarrhea.

In his presentation at the jointly held annual Interscience Conference on Antimicrobial Agents and Chemotherapy and the annual meeting of the Infectious Diseases Society of America, Dr. Delgado-Iribarren reported that “our data were essentially identical for all three groups,” with “a similar proportion of around 20% of patients with diarrhea” and no statistically significant differences among the three groups.

The secondary end points were also mostly similar. Duration of diarrhea was about 3 days, with a maximum of about five stools per day. Controls had a slightly longer average hospital stay than did patients who took the probiotic yogurt.“There were no differences in mortality in the three groups,” he noted.

“We conclude that probiotic yogurt does not have an effect on … antibiotic-associated diarrhea in adults,” Dr. Delgado-Iribarren said. It is, however, safe, he added.

Dr. Delgado-Iribarren did not disclose any conflicts of interest.

WASHINGTON — Probiotic yogurt did not prevent antibiotic-associated diarrhea in a randomized, double-blind trial of about 300 adult patients.

According to the study authors, meta-analyses have suggested that probiotics may be helpful for antibiotic-associated diarrhea, but few large, randomized, controlled trials have been conducted.

A 2007 study did find that probiotics helped prevent antibiotic-associated diarrhea, but the study was fairly small (Can. J. Gastroenterol. 2007;21:732–6).

In the current study, Dr. Alberto Delgado-Iribarren of the microbiology department at the Hospital Universitario Fundación Alcorcón, Madrid, and his colleagues studied more than 300 patients who were admitted to the hospital and started on an antibiotic regimen of either levofloxacin or amoxicillin clavulanate. The mean age of the patients was 76 years; 46% were women.

In all, 122 patients were randomized to receive placebo yogurt (which contained Streptococcus thermophilus and Lactobacillus bulgaricus but no probiotics), another 125 patients were given a probiotic yogurt mixture specially manufactured for the study (which included both S. thermophilus and L. bulgaricus, as well as L. acidophilus, Bifidobacterium lactis, and L. casei), and 65 patients were randomized to receive no yogurt. The yogurt was given in doses of 150–200 mL. Both yogurts had the same taste, color, smell, and texture.

Patients consumed the yogurt from the beginning of antibiotic treatment to 5 days after discontinuing the antibiotic, and the follow-up period was 1 month.

The patients answered a questionnaire about diarrhea and side effects. Diarrhea was defined as two or more soft stools. Secondary end points included number of days of diarrhea, severity of diarrhea, number of stools per day, and longer hospital stay because of diarrhea.

In his presentation at the jointly held annual Interscience Conference on Antimicrobial Agents and Chemotherapy and the annual meeting of the Infectious Diseases Society of America, Dr. Delgado-Iribarren reported that “our data were essentially identical for all three groups,” with “a similar proportion of around 20% of patients with diarrhea” and no statistically significant differences among the three groups.

The secondary end points were also mostly similar. Duration of diarrhea was about 3 days, with a maximum of about five stools per day. Controls had a slightly longer average hospital stay than did patients who took the probiotic yogurt.“There were no differences in mortality in the three groups,” he noted.

“We conclude that probiotic yogurt does not have an effect on … antibiotic-associated diarrhea in adults,” Dr. Delgado-Iribarren said. It is, however, safe, he added.

Dr. Delgado-Iribarren did not disclose any conflicts of interest.

WASHINGTON — In a recent survey of Canadian hospital workers, most said they would be willing to be immunized against pertussis for free, but only a third said they would do so if the vaccine cost over $30.

Moreover, despite a high level of knowledge about pertussis among respondents, just 45% believed that the vaccine was safe and only 40% believed that it was effective.

Dr. Karina A. Top, who was a pediatric resident at Dalhousie University in Halifax, N.S., at the time of the study, presented data from 529 pediatric hospital workers at the facility who responded to a short survey about pertussis. The survey objectives were to assess knowledge and attitudes of the staff regarding pertussis and the pertussis vaccine (Tdap), and to gauge the acceptability of vaccination, she said in a poster at the jointly held annual Interscience Conference on Antimicrobial Agents and Chemotherapy and the annual meeting of the Infectious Diseases Society of America.

The 529 respondents represented 17% of the total 3,051 employees at IWK Health Centre, Halifax (including employees with and without direct patient interaction), said Dr. Top, now a pediatric infectious disease fellow at Columbia University in New York. Only two-thirds of the respondents were able to answer at least 60% of questions about pertussis correctly. Overall, 78% indicated on the survey that they would get immunized if the vaccine were free. If the vaccine were offered at a cost of $40 Canadian (about $32 US), only 30% of the respondents said they would be willing to get vaccinated. Respondents who had not received a flu vaccine were less likely to consider pertussis immunization.

Ultimately, only 61 of the 529 respondents received the vaccine, Dr. Top said in an interview. The results point to a possible need for public funding to ensure that employees of health care facilities are properly vaccinated, Dr. Top said. “It's a matter of cost and convenience.”

Study coauthor Dr. Scott Halperin, director of the Canadian Centre for Vaccinology, Halifax, said that the problem of low vaccination rates among health care workers is not limited to pertussis. “Influenza vaccination rates are typically below 60% when the targets are over 80%–90%,” Dr. Halperin said. “This puts health care workers and their patients at risk.”

The vaccine used in the study was provided by Sanofi-Pasteur, maker of the Tdap vaccine Adacel. Neither Dr. Top nor Dr. Halperin disclosed any personal conflicts of interest.

WASHINGTON — In a recent survey of Canadian hospital workers, most said they would be willing to be immunized against pertussis for free, but only a third said they would do so if the vaccine cost over $30.

Moreover, despite a high level of knowledge about pertussis among respondents, just 45% believed that the vaccine was safe and only 40% believed that it was effective.

Dr. Karina A. Top, who was a pediatric resident at Dalhousie University in Halifax, N.S., at the time of the study, presented data from 529 pediatric hospital workers at the facility who responded to a short survey about pertussis. The survey objectives were to assess knowledge and attitudes of the staff regarding pertussis and the pertussis vaccine (Tdap), and to gauge the acceptability of vaccination, she said in a poster at the jointly held annual Interscience Conference on Antimicrobial Agents and Chemotherapy and the annual meeting of the Infectious Diseases Society of America.

The 529 respondents represented 17% of the total 3,051 employees at IWK Health Centre, Halifax (including employees with and without direct patient interaction), said Dr. Top, now a pediatric infectious disease fellow at Columbia University in New York. Only two-thirds of the respondents were able to answer at least 60% of questions about pertussis correctly. Overall, 78% indicated on the survey that they would get immunized if the vaccine were free. If the vaccine were offered at a cost of $40 Canadian (about $32 US), only 30% of the respondents said they would be willing to get vaccinated. Respondents who had not received a flu vaccine were less likely to consider pertussis immunization.

Ultimately, only 61 of the 529 respondents received the vaccine, Dr. Top said in an interview. The results point to a possible need for public funding to ensure that employees of health care facilities are properly vaccinated, Dr. Top said. “It's a matter of cost and convenience.”

Study coauthor Dr. Scott Halperin, director of the Canadian Centre for Vaccinology, Halifax, said that the problem of low vaccination rates among health care workers is not limited to pertussis. “Influenza vaccination rates are typically below 60% when the targets are over 80%–90%,” Dr. Halperin said. “This puts health care workers and their patients at risk.”

The vaccine used in the study was provided by Sanofi-Pasteur, maker of the Tdap vaccine Adacel. Neither Dr. Top nor Dr. Halperin disclosed any personal conflicts of interest.

WASHINGTON — In a recent survey of Canadian hospital workers, most said they would be willing to be immunized against pertussis for free, but only a third said they would do so if the vaccine cost over $30.

Moreover, despite a high level of knowledge about pertussis among respondents, just 45% believed that the vaccine was safe and only 40% believed that it was effective.

Dr. Karina A. Top, who was a pediatric resident at Dalhousie University in Halifax, N.S., at the time of the study, presented data from 529 pediatric hospital workers at the facility who responded to a short survey about pertussis. The survey objectives were to assess knowledge and attitudes of the staff regarding pertussis and the pertussis vaccine (Tdap), and to gauge the acceptability of vaccination, she said in a poster at the jointly held annual Interscience Conference on Antimicrobial Agents and Chemotherapy and the annual meeting of the Infectious Diseases Society of America.

The 529 respondents represented 17% of the total 3,051 employees at IWK Health Centre, Halifax (including employees with and without direct patient interaction), said Dr. Top, now a pediatric infectious disease fellow at Columbia University in New York. Only two-thirds of the respondents were able to answer at least 60% of questions about pertussis correctly. Overall, 78% indicated on the survey that they would get immunized if the vaccine were free. If the vaccine were offered at a cost of $40 Canadian (about $32 US), only 30% of the respondents said they would be willing to get vaccinated. Respondents who had not received a flu vaccine were less likely to consider pertussis immunization.

Ultimately, only 61 of the 529 respondents received the vaccine, Dr. Top said in an interview. The results point to a possible need for public funding to ensure that employees of health care facilities are properly vaccinated, Dr. Top said. “It's a matter of cost and convenience.”

Study coauthor Dr. Scott Halperin, director of the Canadian Centre for Vaccinology, Halifax, said that the problem of low vaccination rates among health care workers is not limited to pertussis. “Influenza vaccination rates are typically below 60% when the targets are over 80%–90%,” Dr. Halperin said. “This puts health care workers and their patients at risk.”

The vaccine used in the study was provided by Sanofi-Pasteur, maker of the Tdap vaccine Adacel. Neither Dr. Top nor Dr. Halperin disclosed any personal conflicts of interest.

WASHINGTON — Cryptococcus gattii, a meningitis-causing fungus previously confined to tropical and subtropical climates outside of the United States, has caused severe illness in at least 19 individuals—of whom 4 died—in the Pacific Northwest United States since 2006.

The infections were not predominately associated with immunocompromised individuals, unlike past, non-gattii cases of Cryptococcus infection in North America.

“Twelve of 19 individuals had a delay in diagnosis greater than a week,” said Dr. Sarah West at the jointly held annual Interscience Conference on Antimicrobial Agents and Chemotherapy and the annual meeting of the Infectious Diseases Society of America.

The delay was “in part probably because this was not on physicians' radars, and also because this is not something that our labs are routinely testing,” she said, speaking of a need for physicians, especially in that area, to be more aware of the infection.

The outbreak was previously reported on Vancouver Island in 1999, when more than 200 cases were identified. Although a C. gattii relative—Cryptococcus neoformans—is fairly well known in North America, C. gattii was “not previously described as causing significant disease in North America,” Dr. West said.

The variation is most often seen in Australia, where it is especially associated with eucalyptus trees, and in similarly tropical climates. It is not known why or how the fungus has spread to this new area. Previous studies have speculated that it is related to climate change.

Dr. West and her collaborators first had their interest piqued by a published 2006 case of a man from Puget Sound region of Washington state, who had pulmonary cryptococcoma and who was infected with C. gattii. “He had never traveled to Vancouver Island,” she said, though the C. gattii isolate was genetically identical to the Vancouver strain.

Since then, Dr. West has been querying physicians in Oregon and Washington, checking referrals to local tertiary-care hospitals, and relying on “word of mouth” to put together a retrospective study of 19 culture-confirmed C. gattii cases in the region from 2004 to the present. (Most microbiology labs do not routinely differentiate between C. neoformans and C. gattii in cultures, so the cases were culture confirmed in Dr. West's lab.)

“The bulk of cases were in 2007 and 2008,” she said, with patient age ranging from 15 to 87 years (average, 51 years). “At least three had traveled to British Columbia mainland, but none had documented travel to Vancouver Island.,”

“When we compared the Cryptococcus data from Oregon with our C. gattii cases, we saw some differences in the underlying conditions,” she said. Whereas about 78% of the non-gattii Cryptococcus cases in Oregon were associated with HIV, cancer, organ transplants, or some other immunosuppressing condition, “just under 40% of the gattii cases were associated with these diagnoses, and none of the patients with gattii were HIV positive.”

Their presenting symptoms were nonspecific, “which also probably led to some delay in diagnosis,” added Dr. West, of the Oregon Health and Science University, Portland. As on Vancouver Island, about 75% of cases were associated with pulmonary disease of some kind, including two cases of asymptomatic pulmonary nodules. The remaining 25% were associated with central nervous system disease alone. Overall, about 20% of patients had both CNS disease and pulmonary disease.

“Most of the patients with CNS disease had meningoencephalitis, often associated with severe and symptomatic increase in cranial pressure, and many required semipermanent drain placement,” Dr. West said.

All of the patients required prolonged courses of therapy, she said, “longer than is typically given for Cryptococcus neoformans.”

Poor outcomes were seen even in the 15 patients who survived, including long-term sequelae such as chronic headaches, vision loss, hearing loss, and recurrent, longer hospital stays requiring more intensive care.

An audience member from the Centers for Disease Control and Prevention said that the agency has formed a six-state public health working group for C. gattii and has since identified additional cases in Montana and Idaho.

Enzon Pharmaceuticals Inc. supported Dr. West's study. She did not disclose any conflicts of interest related to the study.

WASHINGTON — Cryptococcus gattii, a meningitis-causing fungus previously confined to tropical and subtropical climates outside of the United States, has caused severe illness in at least 19 individuals—of whom 4 died—in the Pacific Northwest United States since 2006.

The infections were not predominately associated with immunocompromised individuals, unlike past, non-gattii cases of Cryptococcus infection in North America.

“Twelve of 19 individuals had a delay in diagnosis greater than a week,” said Dr. Sarah West at the jointly held annual Interscience Conference on Antimicrobial Agents and Chemotherapy and the annual meeting of the Infectious Diseases Society of America.

The delay was “in part probably because this was not on physicians' radars, and also because this is not something that our labs are routinely testing,” she said, speaking of a need for physicians, especially in that area, to be more aware of the infection.

The outbreak was previously reported on Vancouver Island in 1999, when more than 200 cases were identified. Although a C. gattii relative—Cryptococcus neoformans—is fairly well known in North America, C. gattii was “not previously described as causing significant disease in North America,” Dr. West said.

The variation is most often seen in Australia, where it is especially associated with eucalyptus trees, and in similarly tropical climates. It is not known why or how the fungus has spread to this new area. Previous studies have speculated that it is related to climate change.

Dr. West and her collaborators first had their interest piqued by a published 2006 case of a man from Puget Sound region of Washington state, who had pulmonary cryptococcoma and who was infected with C. gattii. “He had never traveled to Vancouver Island,” she said, though the C. gattii isolate was genetically identical to the Vancouver strain.

Since then, Dr. West has been querying physicians in Oregon and Washington, checking referrals to local tertiary-care hospitals, and relying on “word of mouth” to put together a retrospective study of 19 culture-confirmed C. gattii cases in the region from 2004 to the present. (Most microbiology labs do not routinely differentiate between C. neoformans and C. gattii in cultures, so the cases were culture confirmed in Dr. West's lab.)

“The bulk of cases were in 2007 and 2008,” she said, with patient age ranging from 15 to 87 years (average, 51 years). “At least three had traveled to British Columbia mainland, but none had documented travel to Vancouver Island.,”

“When we compared the Cryptococcus data from Oregon with our C. gattii cases, we saw some differences in the underlying conditions,” she said. Whereas about 78% of the non-gattii Cryptococcus cases in Oregon were associated with HIV, cancer, organ transplants, or some other immunosuppressing condition, “just under 40% of the gattii cases were associated with these diagnoses, and none of the patients with gattii were HIV positive.”

Their presenting symptoms were nonspecific, “which also probably led to some delay in diagnosis,” added Dr. West, of the Oregon Health and Science University, Portland. As on Vancouver Island, about 75% of cases were associated with pulmonary disease of some kind, including two cases of asymptomatic pulmonary nodules. The remaining 25% were associated with central nervous system disease alone. Overall, about 20% of patients had both CNS disease and pulmonary disease.

“Most of the patients with CNS disease had meningoencephalitis, often associated with severe and symptomatic increase in cranial pressure, and many required semipermanent drain placement,” Dr. West said.

All of the patients required prolonged courses of therapy, she said, “longer than is typically given for Cryptococcus neoformans.”

Poor outcomes were seen even in the 15 patients who survived, including long-term sequelae such as chronic headaches, vision loss, hearing loss, and recurrent, longer hospital stays requiring more intensive care.

An audience member from the Centers for Disease Control and Prevention said that the agency has formed a six-state public health working group for C. gattii and has since identified additional cases in Montana and Idaho.

Enzon Pharmaceuticals Inc. supported Dr. West's study. She did not disclose any conflicts of interest related to the study.

WASHINGTON — Cryptococcus gattii, a meningitis-causing fungus previously confined to tropical and subtropical climates outside of the United States, has caused severe illness in at least 19 individuals—of whom 4 died—in the Pacific Northwest United States since 2006.

The infections were not predominately associated with immunocompromised individuals, unlike past, non-gattii cases of Cryptococcus infection in North America.

“Twelve of 19 individuals had a delay in diagnosis greater than a week,” said Dr. Sarah West at the jointly held annual Interscience Conference on Antimicrobial Agents and Chemotherapy and the annual meeting of the Infectious Diseases Society of America.

The delay was “in part probably because this was not on physicians' radars, and also because this is not something that our labs are routinely testing,” she said, speaking of a need for physicians, especially in that area, to be more aware of the infection.

The outbreak was previously reported on Vancouver Island in 1999, when more than 200 cases were identified. Although a C. gattii relative—Cryptococcus neoformans—is fairly well known in North America, C. gattii was “not previously described as causing significant disease in North America,” Dr. West said.

The variation is most often seen in Australia, where it is especially associated with eucalyptus trees, and in similarly tropical climates. It is not known why or how the fungus has spread to this new area. Previous studies have speculated that it is related to climate change.

Dr. West and her collaborators first had their interest piqued by a published 2006 case of a man from Puget Sound region of Washington state, who had pulmonary cryptococcoma and who was infected with C. gattii. “He had never traveled to Vancouver Island,” she said, though the C. gattii isolate was genetically identical to the Vancouver strain.

Since then, Dr. West has been querying physicians in Oregon and Washington, checking referrals to local tertiary-care hospitals, and relying on “word of mouth” to put together a retrospective study of 19 culture-confirmed C. gattii cases in the region from 2004 to the present. (Most microbiology labs do not routinely differentiate between C. neoformans and C. gattii in cultures, so the cases were culture confirmed in Dr. West's lab.)

“The bulk of cases were in 2007 and 2008,” she said, with patient age ranging from 15 to 87 years (average, 51 years). “At least three had traveled to British Columbia mainland, but none had documented travel to Vancouver Island.,”

“When we compared the Cryptococcus data from Oregon with our C. gattii cases, we saw some differences in the underlying conditions,” she said. Whereas about 78% of the non-gattii Cryptococcus cases in Oregon were associated with HIV, cancer, organ transplants, or some other immunosuppressing condition, “just under 40% of the gattii cases were associated with these diagnoses, and none of the patients with gattii were HIV positive.”

Their presenting symptoms were nonspecific, “which also probably led to some delay in diagnosis,” added Dr. West, of the Oregon Health and Science University, Portland. As on Vancouver Island, about 75% of cases were associated with pulmonary disease of some kind, including two cases of asymptomatic pulmonary nodules. The remaining 25% were associated with central nervous system disease alone. Overall, about 20% of patients had both CNS disease and pulmonary disease.

“Most of the patients with CNS disease had meningoencephalitis, often associated with severe and symptomatic increase in cranial pressure, and many required semipermanent drain placement,” Dr. West said.

All of the patients required prolonged courses of therapy, she said, “longer than is typically given for Cryptococcus neoformans.”

Poor outcomes were seen even in the 15 patients who survived, including long-term sequelae such as chronic headaches, vision loss, hearing loss, and recurrent, longer hospital stays requiring more intensive care.

An audience member from the Centers for Disease Control and Prevention said that the agency has formed a six-state public health working group for C. gattii and has since identified additional cases in Montana and Idaho.

Enzon Pharmaceuticals Inc. supported Dr. West's study. She did not disclose any conflicts of interest related to the study.

WASHINGTON — Two years after approval of an oral rotavirus vaccine, pediatric rotavirus cases and hospitalizations in U.S. hospitals have decreased dramatically, according to two national studies as well as a number of local analyses.

That decline is present in nonvaccinated age groups, likely because of reduced overall circulation and transmission of the virus in children of all ages, say researchers.

At the joint annual Interscience Conference on Antimicrobial Agents and Chemotherapy and annual meeting of the Infectious Diseases Society of America, T. Christopher Mast, Ph.D., associate director of the department of epidemiology at Merck & Co. (maker of the oral RotaTeq vaccine), reported on 33,135 infants who received all three vaccine doses between Jan. 1, 2007, and April 30, 2007, and 27,954 infants who had received multiple vaccines—but not the rotavirus vaccine—during that time.

The nonrandomized, claims-based observational study data showed a 100% reduction in combined hospital and emergency department (ED) visits in the vaccinated group during the 2007 and 2008 seasons (from January through May). Physician visits were cut by 96% in the vaccinated group, compared with the unvaccinated group. Associated medical costs resulting from hospitalization and ED visits were cut by $12,000 in the vaccinated group, compared with those in the unvaccinated group.

In a second presentation, Dr. Jay Lieberman, medical director for infectious disease for Quest Diagnostics Inc., reported on national rotavirus testing data from Quest's information data warehouse. In the three seasons before licensure of the vaccine (December through June of 2003–2004, 2004–2005, and 2005–2006), 27,625 rotavirus tests on average were performed during the peak disease season, of which 7,162 (26%) were positive. In contrast, in the most recent peak season (from December 2007 through June 2008), 1,703 (8%) of the 21,873 tests performed were found to be positive—a highly significant reduction.

Moreover, “the number of positive tests and the positivity rate declined after vaccine licensure in every age group, including those [aged] 2–5 years, who are unlikely to have been vaccinated,” he wrote in a poster, evidencing herd immunity.

The decline in rotavirus also was shown in several regional studies on the efficacy of RotaTeq. In one of at least eight such posters, Dr. Irini Daskalaki of Drexel University in Philadelphia found a decrease in hospitalizations at St. Christopher's Hospital for Children (also in Philadelphia) ranging from 20% to 94% among different age groups at 1 full year after vaccine implementation. And, as in Dr. Lieberman's study, prominent decreases were seen even in unvaccinated age groups.

Neither Dr. Lieberman nor Dr. Daskalaki disclosed any conflicts of interest.

Data from the U.S. VAERS (Vaccine Adverse Event Reporting System) also presented in a poster at the meeting, confirmed the results of prelicensure studies of the vaccine's safety: Of 21,093,180 doses administered between Feb. 1, 2006, and Aug. 30, 2008, according to Merck, 2,600 adverse event reports were filed with VAERS, 683 (26%) of which were serious. Of the serious reports, 328 (48%) involved cases of intussusception, a rate that was not considered sufficient to cause concern. The other adverse events were vomiting and diarrhea. There was one death.

RotaTeq—a live, oral, human-bovine reassortment rotavirus vaccine—was licensed in February 2006, and routine vaccination was recommended by the Centers for Disease Control's Advisory Committee on Immunization Practices (ACIP) later that year. It is administered in three doses before 32 weeks of age. It is the second rotavirus vaccine to be approved in the United States. The first, RotaShield, was removed from the market in 1999 because of a detected increase in intussusceptions.

A two-dose oral rotavirus vaccine, Rotarix (from GlaxoSmithKline) also was approved by the Food and Drug Administration in April of this year.

WASHINGTON — Two years after approval of an oral rotavirus vaccine, pediatric rotavirus cases and hospitalizations in U.S. hospitals have decreased dramatically, according to two national studies as well as a number of local analyses.

That decline is present in nonvaccinated age groups, likely because of reduced overall circulation and transmission of the virus in children of all ages, say researchers.

At the joint annual Interscience Conference on Antimicrobial Agents and Chemotherapy and annual meeting of the Infectious Diseases Society of America, T. Christopher Mast, Ph.D., associate director of the department of epidemiology at Merck & Co. (maker of the oral RotaTeq vaccine), reported on 33,135 infants who received all three vaccine doses between Jan. 1, 2007, and April 30, 2007, and 27,954 infants who had received multiple vaccines—but not the rotavirus vaccine—during that time.

The nonrandomized, claims-based observational study data showed a 100% reduction in combined hospital and emergency department (ED) visits in the vaccinated group during the 2007 and 2008 seasons (from January through May). Physician visits were cut by 96% in the vaccinated group, compared with the unvaccinated group. Associated medical costs resulting from hospitalization and ED visits were cut by $12,000 in the vaccinated group, compared with those in the unvaccinated group.

In a second presentation, Dr. Jay Lieberman, medical director for infectious disease for Quest Diagnostics Inc., reported on national rotavirus testing data from Quest's information data warehouse. In the three seasons before licensure of the vaccine (December through June of 2003–2004, 2004–2005, and 2005–2006), 27,625 rotavirus tests on average were performed during the peak disease season, of which 7,162 (26%) were positive. In contrast, in the most recent peak season (from December 2007 through June 2008), 1,703 (8%) of the 21,873 tests performed were found to be positive—a highly significant reduction.

Moreover, “the number of positive tests and the positivity rate declined after vaccine licensure in every age group, including those [aged] 2–5 years, who are unlikely to have been vaccinated,” he wrote in a poster, evidencing herd immunity.

The decline in rotavirus also was shown in several regional studies on the efficacy of RotaTeq. In one of at least eight such posters, Dr. Irini Daskalaki of Drexel University in Philadelphia found a decrease in hospitalizations at St. Christopher's Hospital for Children (also in Philadelphia) ranging from 20% to 94% among different age groups at 1 full year after vaccine implementation. And, as in Dr. Lieberman's study, prominent decreases were seen even in unvaccinated age groups.

Neither Dr. Lieberman nor Dr. Daskalaki disclosed any conflicts of interest.

Data from the U.S. VAERS (Vaccine Adverse Event Reporting System) also presented in a poster at the meeting, confirmed the results of prelicensure studies of the vaccine's safety: Of 21,093,180 doses administered between Feb. 1, 2006, and Aug. 30, 2008, according to Merck, 2,600 adverse event reports were filed with VAERS, 683 (26%) of which were serious. Of the serious reports, 328 (48%) involved cases of intussusception, a rate that was not considered sufficient to cause concern. The other adverse events were vomiting and diarrhea. There was one death.

RotaTeq—a live, oral, human-bovine reassortment rotavirus vaccine—was licensed in February 2006, and routine vaccination was recommended by the Centers for Disease Control's Advisory Committee on Immunization Practices (ACIP) later that year. It is administered in three doses before 32 weeks of age. It is the second rotavirus vaccine to be approved in the United States. The first, RotaShield, was removed from the market in 1999 because of a detected increase in intussusceptions.

A two-dose oral rotavirus vaccine, Rotarix (from GlaxoSmithKline) also was approved by the Food and Drug Administration in April of this year.

WASHINGTON — Two years after approval of an oral rotavirus vaccine, pediatric rotavirus cases and hospitalizations in U.S. hospitals have decreased dramatically, according to two national studies as well as a number of local analyses.

That decline is present in nonvaccinated age groups, likely because of reduced overall circulation and transmission of the virus in children of all ages, say researchers.

At the joint annual Interscience Conference on Antimicrobial Agents and Chemotherapy and annual meeting of the Infectious Diseases Society of America, T. Christopher Mast, Ph.D., associate director of the department of epidemiology at Merck & Co. (maker of the oral RotaTeq vaccine), reported on 33,135 infants who received all three vaccine doses between Jan. 1, 2007, and April 30, 2007, and 27,954 infants who had received multiple vaccines—but not the rotavirus vaccine—during that time.

The nonrandomized, claims-based observational study data showed a 100% reduction in combined hospital and emergency department (ED) visits in the vaccinated group during the 2007 and 2008 seasons (from January through May). Physician visits were cut by 96% in the vaccinated group, compared with the unvaccinated group. Associated medical costs resulting from hospitalization and ED visits were cut by $12,000 in the vaccinated group, compared with those in the unvaccinated group.

In a second presentation, Dr. Jay Lieberman, medical director for infectious disease for Quest Diagnostics Inc., reported on national rotavirus testing data from Quest's information data warehouse. In the three seasons before licensure of the vaccine (December through June of 2003–2004, 2004–2005, and 2005–2006), 27,625 rotavirus tests on average were performed during the peak disease season, of which 7,162 (26%) were positive. In contrast, in the most recent peak season (from December 2007 through June 2008), 1,703 (8%) of the 21,873 tests performed were found to be positive—a highly significant reduction.

Moreover, “the number of positive tests and the positivity rate declined after vaccine licensure in every age group, including those [aged] 2–5 years, who are unlikely to have been vaccinated,” he wrote in a poster, evidencing herd immunity.

The decline in rotavirus also was shown in several regional studies on the efficacy of RotaTeq. In one of at least eight such posters, Dr. Irini Daskalaki of Drexel University in Philadelphia found a decrease in hospitalizations at St. Christopher's Hospital for Children (also in Philadelphia) ranging from 20% to 94% among different age groups at 1 full year after vaccine implementation. And, as in Dr. Lieberman's study, prominent decreases were seen even in unvaccinated age groups.

Neither Dr. Lieberman nor Dr. Daskalaki disclosed any conflicts of interest.

Data from the U.S. VAERS (Vaccine Adverse Event Reporting System) also presented in a poster at the meeting, confirmed the results of prelicensure studies of the vaccine's safety: Of 21,093,180 doses administered between Feb. 1, 2006, and Aug. 30, 2008, according to Merck, 2,600 adverse event reports were filed with VAERS, 683 (26%) of which were serious. Of the serious reports, 328 (48%) involved cases of intussusception, a rate that was not considered sufficient to cause concern. The other adverse events were vomiting and diarrhea. There was one death.

RotaTeq—a live, oral, human-bovine reassortment rotavirus vaccine—was licensed in February 2006, and routine vaccination was recommended by the Centers for Disease Control's Advisory Committee on Immunization Practices (ACIP) later that year. It is administered in three doses before 32 weeks of age. It is the second rotavirus vaccine to be approved in the United States. The first, RotaShield, was removed from the market in 1999 because of a detected increase in intussusceptions.

A two-dose oral rotavirus vaccine, Rotarix (from GlaxoSmithKline) also was approved by the Food and Drug Administration in April of this year.

Of the 73 pediatric patients who died of influenza-related causes in the United States during the 2006–2007 flu season, 35% had bacterial coinfection—a fivefold increase over the 2004–2005 season.

Most often, that bacteria was methicillin-resistant Staphylococcus aureus (MRSA).

“Physicians should consider treating children with suspected S. aureus pneumonia during influenza season with vancomycin or other antibiotics to treat MRSA when [the children] reside in areas where MRSA is prevalent” or when they have additional MRSA risk factors, including underlying conditions or a history of infection, wrote Lyn Finelli, of the National Center for Immunization and Respiratory Diseases, Atlanta, and colleagues (Pediatrics 2008;122;805–11).

Dr. Henry Bernstein, a pediatrician in Lebanon, N.H., and a member of the American Academy of Pediatrics' committee on infectious diseases, agreed.

“It's something that we as practicing pediatricians need to be aware of: When somebody gets the flu, we must evaluate whether in fact it's a typical, routine case of the flu or it's something more, if it's not following the course that we expect.”

But the most important lesson from this analysis is to get children vaccinated, Dr. Bernstein said in an interview. “Half of those [deaths] are in kids who could have gotten the flu vaccine, and potentially it could have been prevented. So that's tragic. These aren't just kids who have chronic health conditions. Many of these kids were healthy children. That's a shame,” said Dr. Bernstein, who was not involved in the study.

The researchers defined an influenza season as lasting from Oct. 1 to Sept. 30 of the following year, such that the 2006–2007 season lasted from Oct. 1, 2006, to Sept. 30, 2007. They also defined a child as being fully vaccinated when he or she had received the appropriate number of doses at least 14 days before illness onset.

In the first season looked at, 2004–2005, the rate of bacterial coinfection in the 47 pediatric influenza-related deaths was 6%. By the next season, it was 15%, and by 2006–2007, the rate was 35%. “Overall, S. aureus was isolated from a sterile site or endotracheal tube culture in 1 child in 2004–2005, 3 children in 2005–2006, and 22 children in 2006–2007,” wrote the authors. Of these 26 infections, 15 were MRSA, 6 were methicillin-susceptible S. aureus (MSSA) and 5 were S. aureus of unknown susceptibility.

The authors hypothesized that influenza might increase patient vulnerability to bacteria by damaging the epithelial layer of the tracheobronchial tree, “enhancing staphylococcal adherence,” or possibly suppressing the “respiratory burst response” and phagocytic activities that occur in a healthy immune system.

Regardless of the mechanism, they conceded that there is likely underreporting of bacterial coinfection in fatal influenza cases in the United States. Indeed, according to the authors, flu-related deaths may themselves be underreported: “Despite the availability … of influenza tests, influenza testing is not currently routinely incorporated into the diagnostic work-up of most children who are seen in primary care of emergency department settings with influenza-like illness.”

In all, 166 children in the United States died of influenza-related causes between Oct. 1, 2004, and Sept. 30, 2007. The ages of affected children ranged from 0 to 17 years. The median ages in the three cohorts ranged from 3 to 7 years.

Currently, all children aged 6 months to 18 years should be vaccinated, according to recommendations by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices. Only 5% of those patients for whom vaccination was recommended had received the vaccine.

“Influenza is a serious disease,” said Dr. Bernstein. However, “There's no question that influenza is [also] vaccine preventable. You can't die from the flu if you don't get the flu.” And as the potential for coinfection with antibiotic-resistant bacteria increases from year to year, the need for vaccination is even more pressing, he said. And not just among patients.

“Health care personnel vaccination rates are somewhere around 50%, at most,” he said. “There's certainly room for improvement. Getting a flu vaccine every year ought to become a routine.”

The authors disclosed no conflicts of interest.

Of the 73 pediatric patients who died of influenza-related causes in the United States during the 2006–2007 flu season, 35% had bacterial coinfection—a fivefold increase over the 2004–2005 season.

Most often, that bacteria was methicillin-resistant Staphylococcus aureus (MRSA).

“Physicians should consider treating children with suspected S. aureus pneumonia during influenza season with vancomycin or other antibiotics to treat MRSA when [the children] reside in areas where MRSA is prevalent” or when they have additional MRSA risk factors, including underlying conditions or a history of infection, wrote Lyn Finelli, of the National Center for Immunization and Respiratory Diseases, Atlanta, and colleagues (Pediatrics 2008;122;805–11).

Dr. Henry Bernstein, a pediatrician in Lebanon, N.H., and a member of the American Academy of Pediatrics' committee on infectious diseases, agreed.

“It's something that we as practicing pediatricians need to be aware of: When somebody gets the flu, we must evaluate whether in fact it's a typical, routine case of the flu or it's something more, if it's not following the course that we expect.”

But the most important lesson from this analysis is to get children vaccinated, Dr. Bernstein said in an interview. “Half of those [deaths] are in kids who could have gotten the flu vaccine, and potentially it could have been prevented. So that's tragic. These aren't just kids who have chronic health conditions. Many of these kids were healthy children. That's a shame,” said Dr. Bernstein, who was not involved in the study.

The researchers defined an influenza season as lasting from Oct. 1 to Sept. 30 of the following year, such that the 2006–2007 season lasted from Oct. 1, 2006, to Sept. 30, 2007. They also defined a child as being fully vaccinated when he or she had received the appropriate number of doses at least 14 days before illness onset.

In the first season looked at, 2004–2005, the rate of bacterial coinfection in the 47 pediatric influenza-related deaths was 6%. By the next season, it was 15%, and by 2006–2007, the rate was 35%. “Overall, S. aureus was isolated from a sterile site or endotracheal tube culture in 1 child in 2004–2005, 3 children in 2005–2006, and 22 children in 2006–2007,” wrote the authors. Of these 26 infections, 15 were MRSA, 6 were methicillin-susceptible S. aureus (MSSA) and 5 were S. aureus of unknown susceptibility.

The authors hypothesized that influenza might increase patient vulnerability to bacteria by damaging the epithelial layer of the tracheobronchial tree, “enhancing staphylococcal adherence,” or possibly suppressing the “respiratory burst response” and phagocytic activities that occur in a healthy immune system.

Regardless of the mechanism, they conceded that there is likely underreporting of bacterial coinfection in fatal influenza cases in the United States. Indeed, according to the authors, flu-related deaths may themselves be underreported: “Despite the availability … of influenza tests, influenza testing is not currently routinely incorporated into the diagnostic work-up of most children who are seen in primary care of emergency department settings with influenza-like illness.”

In all, 166 children in the United States died of influenza-related causes between Oct. 1, 2004, and Sept. 30, 2007. The ages of affected children ranged from 0 to 17 years. The median ages in the three cohorts ranged from 3 to 7 years.

Currently, all children aged 6 months to 18 years should be vaccinated, according to recommendations by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices. Only 5% of those patients for whom vaccination was recommended had received the vaccine.

“Influenza is a serious disease,” said Dr. Bernstein. However, “There's no question that influenza is [also] vaccine preventable. You can't die from the flu if you don't get the flu.” And as the potential for coinfection with antibiotic-resistant bacteria increases from year to year, the need for vaccination is even more pressing, he said. And not just among patients.

“Health care personnel vaccination rates are somewhere around 50%, at most,” he said. “There's certainly room for improvement. Getting a flu vaccine every year ought to become a routine.”

The authors disclosed no conflicts of interest.

Of the 73 pediatric patients who died of influenza-related causes in the United States during the 2006–2007 flu season, 35% had bacterial coinfection—a fivefold increase over the 2004–2005 season.

Most often, that bacteria was methicillin-resistant Staphylococcus aureus (MRSA).

“Physicians should consider treating children with suspected S. aureus pneumonia during influenza season with vancomycin or other antibiotics to treat MRSA when [the children] reside in areas where MRSA is prevalent” or when they have additional MRSA risk factors, including underlying conditions or a history of infection, wrote Lyn Finelli, of the National Center for Immunization and Respiratory Diseases, Atlanta, and colleagues (Pediatrics 2008;122;805–11).

Dr. Henry Bernstein, a pediatrician in Lebanon, N.H., and a member of the American Academy of Pediatrics' committee on infectious diseases, agreed.

“It's something that we as practicing pediatricians need to be aware of: When somebody gets the flu, we must evaluate whether in fact it's a typical, routine case of the flu or it's something more, if it's not following the course that we expect.”

But the most important lesson from this analysis is to get children vaccinated, Dr. Bernstein said in an interview. “Half of those [deaths] are in kids who could have gotten the flu vaccine, and potentially it could have been prevented. So that's tragic. These aren't just kids who have chronic health conditions. Many of these kids were healthy children. That's a shame,” said Dr. Bernstein, who was not involved in the study.

The researchers defined an influenza season as lasting from Oct. 1 to Sept. 30 of the following year, such that the 2006–2007 season lasted from Oct. 1, 2006, to Sept. 30, 2007. They also defined a child as being fully vaccinated when he or she had received the appropriate number of doses at least 14 days before illness onset.

In the first season looked at, 2004–2005, the rate of bacterial coinfection in the 47 pediatric influenza-related deaths was 6%. By the next season, it was 15%, and by 2006–2007, the rate was 35%. “Overall, S. aureus was isolated from a sterile site or endotracheal tube culture in 1 child in 2004–2005, 3 children in 2005–2006, and 22 children in 2006–2007,” wrote the authors. Of these 26 infections, 15 were MRSA, 6 were methicillin-susceptible S. aureus (MSSA) and 5 were S. aureus of unknown susceptibility.

The authors hypothesized that influenza might increase patient vulnerability to bacteria by damaging the epithelial layer of the tracheobronchial tree, “enhancing staphylococcal adherence,” or possibly suppressing the “respiratory burst response” and phagocytic activities that occur in a healthy immune system.

Regardless of the mechanism, they conceded that there is likely underreporting of bacterial coinfection in fatal influenza cases in the United States. Indeed, according to the authors, flu-related deaths may themselves be underreported: “Despite the availability … of influenza tests, influenza testing is not currently routinely incorporated into the diagnostic work-up of most children who are seen in primary care of emergency department settings with influenza-like illness.”

In all, 166 children in the United States died of influenza-related causes between Oct. 1, 2004, and Sept. 30, 2007. The ages of affected children ranged from 0 to 17 years. The median ages in the three cohorts ranged from 3 to 7 years.

Currently, all children aged 6 months to 18 years should be vaccinated, according to recommendations by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices. Only 5% of those patients for whom vaccination was recommended had received the vaccine.

“Influenza is a serious disease,” said Dr. Bernstein. However, “There's no question that influenza is [also] vaccine preventable. You can't die from the flu if you don't get the flu.” And as the potential for coinfection with antibiotic-resistant bacteria increases from year to year, the need for vaccination is even more pressing, he said. And not just among patients.

“Health care personnel vaccination rates are somewhere around 50%, at most,” he said. “There's certainly room for improvement. Getting a flu vaccine every year ought to become a routine.”

The authors disclosed no conflicts of interest.

WASHINGTON — It is "unconscionable for health care workers who do not have a medical contraindication to not receive the flu vaccine," Dr. Julie L. Gerberding, director of the Centers for Disease Control and Prevention, said at a press briefing presented by the National Foundation for Infectious Diseases.

"We need to create the expectation that this is a given. … It's that important," she emphasized.

A panel of experts at the briefing expressed concern about the low vaccination rate among health care professionals and urged more physicians to get the vaccine this flu season.

"It is both the ethical and professional responsibility of every health care worker to get vaccinated. It is a patient safety issue," said Dr. William Schaffner, chairman of the department of preventive medicine at Vanderbilt University, Nashville, Tenn., and president-elect of the NFID.

Dr. Ardis D. Hoven, an internist and infectious disease specialist in Lexington, Ky., and a member of the American Medical Association's board of directors, encouraged clinicians to vaccinate themselves and to ensure that their staff members also get the shot. It should be given to "anybody who is engaged in providing care within the clinic of the building in which the health care is being provided—medical technicians, nurses, people who are going to be involved in providing some kind of service or care to that patient—in addition to the physician. It's very important and, in most practices, small or large, because we so depend on these people."

Dr. Renée R. Jenkins, president of the American Academy of Pediatrics, emphasized the need for vaccination among children.

"The recommendations from the CDC and the American Academy of Pediatrics are to vaccinate all children 6 months through 18 years of age," she noted. This includes 5- to 18-year-olds, a new group that was added this year. Dr. Jenkins added that during a typical influenza season, up to a third of all children in the United States are infected. In the 2007–2008 season, 86 children died as a result of influenza, and half of those deaths were in children aged 15–17 years.

Turning to the subject of older Medicare patients who are especially vulnerable to influenza-related complications, Kerry Weems of the Centers for Medicare and Medicaid Services emphasized that the vaccine is free, whether it is administered in a doctor's office, a local pharmacy, or in a nonmedical setting such as a grocery store.

"Sadly, in any given state, at least 20% of people with Medicare are not getting their flu shot," said Mr. Weems, the acting administrator of the CMS.

The Medicare reimbursement for the influenza vaccine in the coming year will increase by almost 5%, to $18.20, for the preservative-free vaccine and by slightly more than 1%, to $22.32, for the nasal spray.

The panel also emphasized the need for increased communication between physicians and their patients about the benefits of the flu vaccine.

Dr. Hoven cited data from an NFID telephone survey of 2,029 adults taken in August of this year that showed that nearly 4 in 10 adult patients had never discussed the flu vaccine with their health care professional and that half of those patients who had discussed it had initiated the conversation. Nearly 1 in 5 patients aged 65 years or older and 3 in 10 patients aged 50–64 years had ever discussed vaccine with their health care professional, she added.

These data are especially troubling because a health care professional's recommendation is a strong predictor of whether a patient gets the shot—almost 70% of the NFID survey respondents said they would be very likely or likely to get the vaccine if their health care professional had recommended it.

A total of 261 million people in the United States, or 85% of all Americans, are recommended to be vaccinated this year, including all children aged 6 months through 18 years, all adults aged 50 years and older, all health care professionals, and all pregnant women.

The press conference was sponsored in part by CSL Biotherapies, GlaxoSmithKline PLC, MedImmune Inc., Merck & Co., Novartis Vaccines, Hoffmann-La Roche Inc., and Sanofi Pasteur Inc.

WASHINGTON — It is "unconscionable for health care workers who do not have a medical contraindication to not receive the flu vaccine," Dr. Julie L. Gerberding, director of the Centers for Disease Control and Prevention, said at a press briefing presented by the National Foundation for Infectious Diseases.

"We need to create the expectation that this is a given. … It's that important," she emphasized.

A panel of experts at the briefing expressed concern about the low vaccination rate among health care professionals and urged more physicians to get the vaccine this flu season.

"It is both the ethical and professional responsibility of every health care worker to get vaccinated. It is a patient safety issue," said Dr. William Schaffner, chairman of the department of preventive medicine at Vanderbilt University, Nashville, Tenn., and president-elect of the NFID.

Dr. Ardis D. Hoven, an internist and infectious disease specialist in Lexington, Ky., and a member of the American Medical Association's board of directors, encouraged clinicians to vaccinate themselves and to ensure that their staff members also get the shot. It should be given to "anybody who is engaged in providing care within the clinic of the building in which the health care is being provided—medical technicians, nurses, people who are going to be involved in providing some kind of service or care to that patient—in addition to the physician. It's very important and, in most practices, small or large, because we so depend on these people."

Dr. Renée R. Jenkins, president of the American Academy of Pediatrics, emphasized the need for vaccination among children.

"The recommendations from the CDC and the American Academy of Pediatrics are to vaccinate all children 6 months through 18 years of age," she noted. This includes 5- to 18-year-olds, a new group that was added this year. Dr. Jenkins added that during a typical influenza season, up to a third of all children in the United States are infected. In the 2007–2008 season, 86 children died as a result of influenza, and half of those deaths were in children aged 15–17 years.

Turning to the subject of older Medicare patients who are especially vulnerable to influenza-related complications, Kerry Weems of the Centers for Medicare and Medicaid Services emphasized that the vaccine is free, whether it is administered in a doctor's office, a local pharmacy, or in a nonmedical setting such as a grocery store.

"Sadly, in any given state, at least 20% of people with Medicare are not getting their flu shot," said Mr. Weems, the acting administrator of the CMS.

The Medicare reimbursement for the influenza vaccine in the coming year will increase by almost 5%, to $18.20, for the preservative-free vaccine and by slightly more than 1%, to $22.32, for the nasal spray.

The panel also emphasized the need for increased communication between physicians and their patients about the benefits of the flu vaccine.

Dr. Hoven cited data from an NFID telephone survey of 2,029 adults taken in August of this year that showed that nearly 4 in 10 adult patients had never discussed the flu vaccine with their health care professional and that half of those patients who had discussed it had initiated the conversation. Nearly 1 in 5 patients aged 65 years or older and 3 in 10 patients aged 50–64 years had ever discussed vaccine with their health care professional, she added.

These data are especially troubling because a health care professional's recommendation is a strong predictor of whether a patient gets the shot—almost 70% of the NFID survey respondents said they would be very likely or likely to get the vaccine if their health care professional had recommended it.

A total of 261 million people in the United States, or 85% of all Americans, are recommended to be vaccinated this year, including all children aged 6 months through 18 years, all adults aged 50 years and older, all health care professionals, and all pregnant women.

The press conference was sponsored in part by CSL Biotherapies, GlaxoSmithKline PLC, MedImmune Inc., Merck & Co., Novartis Vaccines, Hoffmann-La Roche Inc., and Sanofi Pasteur Inc.

WASHINGTON — It is "unconscionable for health care workers who do not have a medical contraindication to not receive the flu vaccine," Dr. Julie L. Gerberding, director of the Centers for Disease Control and Prevention, said at a press briefing presented by the National Foundation for Infectious Diseases.

"We need to create the expectation that this is a given. … It's that important," she emphasized.

A panel of experts at the briefing expressed concern about the low vaccination rate among health care professionals and urged more physicians to get the vaccine this flu season.

"It is both the ethical and professional responsibility of every health care worker to get vaccinated. It is a patient safety issue," said Dr. William Schaffner, chairman of the department of preventive medicine at Vanderbilt University, Nashville, Tenn., and president-elect of the NFID.

Dr. Ardis D. Hoven, an internist and infectious disease specialist in Lexington, Ky., and a member of the American Medical Association's board of directors, encouraged clinicians to vaccinate themselves and to ensure that their staff members also get the shot. It should be given to "anybody who is engaged in providing care within the clinic of the building in which the health care is being provided—medical technicians, nurses, people who are going to be involved in providing some kind of service or care to that patient—in addition to the physician. It's very important and, in most practices, small or large, because we so depend on these people."

Dr. Renée R. Jenkins, president of the American Academy of Pediatrics, emphasized the need for vaccination among children.

"The recommendations from the CDC and the American Academy of Pediatrics are to vaccinate all children 6 months through 18 years of age," she noted. This includes 5- to 18-year-olds, a new group that was added this year. Dr. Jenkins added that during a typical influenza season, up to a third of all children in the United States are infected. In the 2007–2008 season, 86 children died as a result of influenza, and half of those deaths were in children aged 15–17 years.

Turning to the subject of older Medicare patients who are especially vulnerable to influenza-related complications, Kerry Weems of the Centers for Medicare and Medicaid Services emphasized that the vaccine is free, whether it is administered in a doctor's office, a local pharmacy, or in a nonmedical setting such as a grocery store.

"Sadly, in any given state, at least 20% of people with Medicare are not getting their flu shot," said Mr. Weems, the acting administrator of the CMS.

The Medicare reimbursement for the influenza vaccine in the coming year will increase by almost 5%, to $18.20, for the preservative-free vaccine and by slightly more than 1%, to $22.32, for the nasal spray.

The panel also emphasized the need for increased communication between physicians and their patients about the benefits of the flu vaccine.

Dr. Hoven cited data from an NFID telephone survey of 2,029 adults taken in August of this year that showed that nearly 4 in 10 adult patients had never discussed the flu vaccine with their health care professional and that half of those patients who had discussed it had initiated the conversation. Nearly 1 in 5 patients aged 65 years or older and 3 in 10 patients aged 50–64 years had ever discussed vaccine with their health care professional, she added.

These data are especially troubling because a health care professional's recommendation is a strong predictor of whether a patient gets the shot—almost 70% of the NFID survey respondents said they would be very likely or likely to get the vaccine if their health care professional had recommended it.

A total of 261 million people in the United States, or 85% of all Americans, are recommended to be vaccinated this year, including all children aged 6 months through 18 years, all adults aged 50 years and older, all health care professionals, and all pregnant women.

The press conference was sponsored in part by CSL Biotherapies, GlaxoSmithKline PLC, MedImmune Inc., Merck & Co., Novartis Vaccines, Hoffmann-La Roche Inc., and Sanofi Pasteur Inc.

WASHINGTON — It is “unconscionable for health care workers who do not have a medical contraindication to not receive the flu vaccine,” Dr. Julie L. Gerberding, director of the Centers for Disease Control and Prevention, said at a press briefing presented by the National Foundation for Infectious Diseases.

“We need to create the expectation that this is a given. … It's that important,” she emphasized.

A panel of experts at the briefing expressed concern about the low vaccination rate among health care professionals and urged more physicians to get the vaccine this flu season.

“It is both the ethical and professional responsibility of every health care worker to get vaccinated. It is a patient safety issue,” said Dr. William Schaffner, chairman of the department of preventive medicine at Vanderbilt University, Nashville, Tenn., and president-elect of NFID.

Dr. Ardis D. Hoven, an internist and infectious disease specialist in Lexington, Ky., and a member of the American Medical Association's board of directors, encouraged clinicians to vaccinate themselves and to ensure that their staff members also get the shot. It should be given to “anybody who is engaged in providing care within the clinic of the building in which the health care is being provided—medical technicians, nurses, people who are going to be involved in providing some kind of service or care to that patient—in addition to the physician. It's very important and, in most practices, small or large, because we so depend on these people.”

Dr. Renée R. Jenkins, president of the American Academy of Pediatrics, emphasized the need for vaccination among children.

“The recommendations from the CDC and the American Academy of Pediatrics are to vaccinate all children 6 months through 18 years of age,” she noted. This includes 5- to 18-year-olds, a new group that was added this year. The burden of disease in this group includes missed school days, increased antibiotic use, doctors' visits, and the economic impact of parents' lost time taking care of them, all of which lent support for the group's inclusion in the recommendations.

Dr. Jenkins added that during a typical influenza season, up to a third of all children in the U.S. are infected. In the 2007–2008 season, 86 children died as a result of influenza, and half of those deaths were in children aged 15–17 years.

The panel also emphasized the need for increased communication between physicians and their patients about the benefits of the flu vaccine.

Dr. Hoven cited data from an NFID telephone survey of 2,029 adults taken in August of this year that showed that nearly 4 in 10 adult patients had never discussed the flu vaccine with their health care professional and that half of those patients who had discussed it had initiated the conversation. Nearly 1 in 5 patients aged 65 years or older and 3 in 10 patients aged 50–64 years had ever discussed vaccine with their health care professional, she added.

These data are especially troubling because a health care professional's recommendation is a strong predictor of whether a patient gets the shot—almost 70% of the NFID survey respondents said they would be very likely or likely to get the vaccine if their health care professional had recommended it.

A total of 261 million people in the United States, or 85% of all Americans, are recommended to be vaccinated this year, including all children aged 6 months through 18 years, all adults aged 50 years and older, all health care professionals, and all pregnant women.

The press conference was sponsored in part by CSL Biotherapies, GlaxoSmithKline PLC, MedImmune Inc., Merck & Co., Novartis Vaccines, Hoffmann-La Roche Inc., and Sanofi Pasteur Inc.

'We need to create the expectation that this is a given. … It's that important.' DR. GERBERDING

WASHINGTON — It is “unconscionable for health care workers who do not have a medical contraindication to not receive the flu vaccine,” Dr. Julie L. Gerberding, director of the Centers for Disease Control and Prevention, said at a press briefing presented by the National Foundation for Infectious Diseases.

“We need to create the expectation that this is a given. … It's that important,” she emphasized.

A panel of experts at the briefing expressed concern about the low vaccination rate among health care professionals and urged more physicians to get the vaccine this flu season.

“It is both the ethical and professional responsibility of every health care worker to get vaccinated. It is a patient safety issue,” said Dr. William Schaffner, chairman of the department of preventive medicine at Vanderbilt University, Nashville, Tenn., and president-elect of NFID.

Dr. Ardis D. Hoven, an internist and infectious disease specialist in Lexington, Ky., and a member of the American Medical Association's board of directors, encouraged clinicians to vaccinate themselves and to ensure that their staff members also get the shot. It should be given to “anybody who is engaged in providing care within the clinic of the building in which the health care is being provided—medical technicians, nurses, people who are going to be involved in providing some kind of service or care to that patient—in addition to the physician. It's very important and, in most practices, small or large, because we so depend on these people.”

Dr. Renée R. Jenkins, president of the American Academy of Pediatrics, emphasized the need for vaccination among children.

“The recommendations from the CDC and the American Academy of Pediatrics are to vaccinate all children 6 months through 18 years of age,” she noted. This includes 5- to 18-year-olds, a new group that was added this year. The burden of disease in this group includes missed school days, increased antibiotic use, doctors' visits, and the economic impact of parents' lost time taking care of them, all of which lent support for the group's inclusion in the recommendations.

Dr. Jenkins added that during a typical influenza season, up to a third of all children in the U.S. are infected. In the 2007–2008 season, 86 children died as a result of influenza, and half of those deaths were in children aged 15–17 years.

The panel also emphasized the need for increased communication between physicians and their patients about the benefits of the flu vaccine.

Dr. Hoven cited data from an NFID telephone survey of 2,029 adults taken in August of this year that showed that nearly 4 in 10 adult patients had never discussed the flu vaccine with their health care professional and that half of those patients who had discussed it had initiated the conversation. Nearly 1 in 5 patients aged 65 years or older and 3 in 10 patients aged 50–64 years had ever discussed vaccine with their health care professional, she added.

These data are especially troubling because a health care professional's recommendation is a strong predictor of whether a patient gets the shot—almost 70% of the NFID survey respondents said they would be very likely or likely to get the vaccine if their health care professional had recommended it.

A total of 261 million people in the United States, or 85% of all Americans, are recommended to be vaccinated this year, including all children aged 6 months through 18 years, all adults aged 50 years and older, all health care professionals, and all pregnant women.

The press conference was sponsored in part by CSL Biotherapies, GlaxoSmithKline PLC, MedImmune Inc., Merck & Co., Novartis Vaccines, Hoffmann-La Roche Inc., and Sanofi Pasteur Inc.

'We need to create the expectation that this is a given. … It's that important.' DR. GERBERDING

WASHINGTON — It is “unconscionable for health care workers who do not have a medical contraindication to not receive the flu vaccine,” Dr. Julie L. Gerberding, director of the Centers for Disease Control and Prevention, said at a press briefing presented by the National Foundation for Infectious Diseases.

“We need to create the expectation that this is a given. … It's that important,” she emphasized.

A panel of experts at the briefing expressed concern about the low vaccination rate among health care professionals and urged more physicians to get the vaccine this flu season.

“It is both the ethical and professional responsibility of every health care worker to get vaccinated. It is a patient safety issue,” said Dr. William Schaffner, chairman of the department of preventive medicine at Vanderbilt University, Nashville, Tenn., and president-elect of NFID.

Dr. Ardis D. Hoven, an internist and infectious disease specialist in Lexington, Ky., and a member of the American Medical Association's board of directors, encouraged clinicians to vaccinate themselves and to ensure that their staff members also get the shot. It should be given to “anybody who is engaged in providing care within the clinic of the building in which the health care is being provided—medical technicians, nurses, people who are going to be involved in providing some kind of service or care to that patient—in addition to the physician. It's very important and, in most practices, small or large, because we so depend on these people.”

Dr. Renée R. Jenkins, president of the American Academy of Pediatrics, emphasized the need for vaccination among children.

“The recommendations from the CDC and the American Academy of Pediatrics are to vaccinate all children 6 months through 18 years of age,” she noted. This includes 5- to 18-year-olds, a new group that was added this year. The burden of disease in this group includes missed school days, increased antibiotic use, doctors' visits, and the economic impact of parents' lost time taking care of them, all of which lent support for the group's inclusion in the recommendations.

Dr. Jenkins added that during a typical influenza season, up to a third of all children in the U.S. are infected. In the 2007–2008 season, 86 children died as a result of influenza, and half of those deaths were in children aged 15–17 years.

The panel also emphasized the need for increased communication between physicians and their patients about the benefits of the flu vaccine.

Dr. Hoven cited data from an NFID telephone survey of 2,029 adults taken in August of this year that showed that nearly 4 in 10 adult patients had never discussed the flu vaccine with their health care professional and that half of those patients who had discussed it had initiated the conversation. Nearly 1 in 5 patients aged 65 years or older and 3 in 10 patients aged 50–64 years had ever discussed vaccine with their health care professional, she added.

These data are especially troubling because a health care professional's recommendation is a strong predictor of whether a patient gets the shot—almost 70% of the NFID survey respondents said they would be very likely or likely to get the vaccine if their health care professional had recommended it.

A total of 261 million people in the United States, or 85% of all Americans, are recommended to be vaccinated this year, including all children aged 6 months through 18 years, all adults aged 50 years and older, all health care professionals, and all pregnant women.

The press conference was sponsored in part by CSL Biotherapies, GlaxoSmithKline PLC, MedImmune Inc., Merck & Co., Novartis Vaccines, Hoffmann-La Roche Inc., and Sanofi Pasteur Inc.

'We need to create the expectation that this is a given. … It's that important.' DR. GERBERDING

If patient-centered medical homes are to be the new standard in care, fee-for-service practices will have to convert to the new model.

Dr. Richard Baron and his four-physician practice in Philadelphia are part of a growing contingent devoted to finding out exactly what that will entail.

“The thinking behind the patient-centered medical home is that if you fund primary care more robustly, you will see decreased costs and increased quality,” Dr. Baron said. “But nobody really knows what particular aspects of primary care are the ones that you should be looking for.”

To try to answer that question, Dr. Baron and his practice, Greenhouse Internists PC, helped to plan and are participating in the Southeastern Pennsylvania Chronic Care Initiative, a medical home demonstration project that is a collaboration of the Pennsylvania Chronic Care Management, Reimbursement, and Cost Reduction Commission and the Patient-Centered Primary Care Collaborative.

“The major interest we had for participating in the pilot was the prospect of increased reimbursement for services that, in our practice, we were already providing—plus some that we would like to be providing but could ill afford to,” he said in an interview.

Greenhouse Internists has made several changes to conform to the 90-page medical home guideline from the National Committee for Quality Assurance (NCQA), which assigns points in each of 10 categories to stratify practices into tier I (minimally compliant), tier II, or tier III medical homes. The measures include things like whether a practice has established written standards for patient communication, whether it uses data to show if standards for patient access and communication are met, and whether a practice uses charting tools to organize clinical information—activities that don't count for much in the current reimbursement system, but that are crucial to the establishment of a medical home.

The first change that Dr. Baron's practice made, even before enrolling in the demonstration project, was the installation of an electronic medical records system. “It cost us $140,000 or $160,000 for a four-doctor group, and we didn't see any increased reimbursement from anybody for having made that investment.” But under the pilot, “there are points we get from the way we use the EMR that allow us somewhat to recoup the investment,” said Dr. Baron, who is also chair of the American Board of Internal Medicine.

Another change was the hiring of a “health educator” to develop systems to fulfill the NCQA guidelines that require patient involvement and education, Dr. Baron said. For example, the health educator has created action plans that remind the physicians to have conversations with diabetes patients about managing blood sugar and weight loss.

“Most of us in primary care know we're supposed to have those conversations, but most of us are so desperate to get through the day that … we don't. It's a workflow issue,” he said. And for those conversations to be reimbursed as part of an integrated medical home, they must be documented in the EMR system.

Greenhouse Internists is also increasing both the number of medical assistants and the number of non-clinically trained staff. “One of the things that you get when you start using the EMR is the ability to look [through the records] for the patients with poorly controlled diabetes whom you haven't seen in 6 months,” Dr. Baron said. “But once we've done that, it isn't obvious who is in the office to pick up the phone and call them.” In a traditional practice, the job would probably fall to the physician. “Doctors get into a pretty toxic spiral. … There isn't anyone to do it, so they do it themselves, and that's the worst answer, because we cost more than anybody.”

Non-clinically trained or nonphysician office staff are “underutilized” in primary care practices, he said. By hiring more nonclinical staff, Greenhouse can relieve physicians of tasks they would otherwise have to do.

In the meantime, Dr. Baron said he knows that the medical home movement is still only in the early stages.

“There's a lot of skepticism in the health care community about whether the patient-centered medical home is a flash in the pan. Is it going to go away?” he asked. And while practices like his participate in demonstrations, “the sad reality is that in a fee-for-service system, [non-visit-based care] takes the doctors off the fee-for-service treadmill, which is how they create income.”

Nevertheless, Dr. Baron is excited to be participating in the demonstration. “On the one hand, it's extra work for a group of people who are already pretty busy. But on the other hand, there's a sense of wonderful opportunity,” he said. “For us, this pilot is a way to recoup investments that we've already made, because we believe in a non-visit-based model of care.”

If patient-centered medical homes are to be the new standard in care, fee-for-service practices will have to convert to the new model.

Dr. Richard Baron and his four-physician practice in Philadelphia are part of a growing contingent devoted to finding out exactly what that will entail.

“The thinking behind the patient-centered medical home is that if you fund primary care more robustly, you will see decreased costs and increased quality,” Dr. Baron said. “But nobody really knows what particular aspects of primary care are the ones that you should be looking for.”

To try to answer that question, Dr. Baron and his practice, Greenhouse Internists PC, helped to plan and are participating in the Southeastern Pennsylvania Chronic Care Initiative, a medical home demonstration project that is a collaboration of the Pennsylvania Chronic Care Management, Reimbursement, and Cost Reduction Commission and the Patient-Centered Primary Care Collaborative.

“The major interest we had for participating in the pilot was the prospect of increased reimbursement for services that, in our practice, we were already providing—plus some that we would like to be providing but could ill afford to,” he said in an interview.

Greenhouse Internists has made several changes to conform to the 90-page medical home guideline from the National Committee for Quality Assurance (NCQA), which assigns points in each of 10 categories to stratify practices into tier I (minimally compliant), tier II, or tier III medical homes. The measures include things like whether a practice has established written standards for patient communication, whether it uses data to show if standards for patient access and communication are met, and whether a practice uses charting tools to organize clinical information—activities that don't count for much in the current reimbursement system, but that are crucial to the establishment of a medical home.

The first change that Dr. Baron's practice made, even before enrolling in the demonstration project, was the installation of an electronic medical records system. “It cost us $140,000 or $160,000 for a four-doctor group, and we didn't see any increased reimbursement from anybody for having made that investment.” But under the pilot, “there are points we get from the way we use the EMR that allow us somewhat to recoup the investment,” said Dr. Baron, who is also chair of the American Board of Internal Medicine.

Another change was the hiring of a “health educator” to develop systems to fulfill the NCQA guidelines that require patient involvement and education, Dr. Baron said. For example, the health educator has created action plans that remind the physicians to have conversations with diabetes patients about managing blood sugar and weight loss.

“Most of us in primary care know we're supposed to have those conversations, but most of us are so desperate to get through the day that … we don't. It's a workflow issue,” he said. And for those conversations to be reimbursed as part of an integrated medical home, they must be documented in the EMR system.

Greenhouse Internists is also increasing both the number of medical assistants and the number of non-clinically trained staff. “One of the things that you get when you start using the EMR is the ability to look [through the records] for the patients with poorly controlled diabetes whom you haven't seen in 6 months,” Dr. Baron said. “But once we've done that, it isn't obvious who is in the office to pick up the phone and call them.” In a traditional practice, the job would probably fall to the physician. “Doctors get into a pretty toxic spiral. … There isn't anyone to do it, so they do it themselves, and that's the worst answer, because we cost more than anybody.”

Non-clinically trained or nonphysician office staff are “underutilized” in primary care practices, he said. By hiring more nonclinical staff, Greenhouse can relieve physicians of tasks they would otherwise have to do.

In the meantime, Dr. Baron said he knows that the medical home movement is still only in the early stages.

“There's a lot of skepticism in the health care community about whether the patient-centered medical home is a flash in the pan. Is it going to go away?” he asked. And while practices like his participate in demonstrations, “the sad reality is that in a fee-for-service system, [non-visit-based care] takes the doctors off the fee-for-service treadmill, which is how they create income.”

Nevertheless, Dr. Baron is excited to be participating in the demonstration. “On the one hand, it's extra work for a group of people who are already pretty busy. But on the other hand, there's a sense of wonderful opportunity,” he said. “For us, this pilot is a way to recoup investments that we've already made, because we believe in a non-visit-based model of care.”

If patient-centered medical homes are to be the new standard in care, fee-for-service practices will have to convert to the new model.

Dr. Richard Baron and his four-physician practice in Philadelphia are part of a growing contingent devoted to finding out exactly what that will entail.

“The thinking behind the patient-centered medical home is that if you fund primary care more robustly, you will see decreased costs and increased quality,” Dr. Baron said. “But nobody really knows what particular aspects of primary care are the ones that you should be looking for.”

To try to answer that question, Dr. Baron and his practice, Greenhouse Internists PC, helped to plan and are participating in the Southeastern Pennsylvania Chronic Care Initiative, a medical home demonstration project that is a collaboration of the Pennsylvania Chronic Care Management, Reimbursement, and Cost Reduction Commission and the Patient-Centered Primary Care Collaborative.

“The major interest we had for participating in the pilot was the prospect of increased reimbursement for services that, in our practice, we were already providing—plus some that we would like to be providing but could ill afford to,” he said in an interview.

Greenhouse Internists has made several changes to conform to the 90-page medical home guideline from the National Committee for Quality Assurance (NCQA), which assigns points in each of 10 categories to stratify practices into tier I (minimally compliant), tier II, or tier III medical homes. The measures include things like whether a practice has established written standards for patient communication, whether it uses data to show if standards for patient access and communication are met, and whether a practice uses charting tools to organize clinical information—activities that don't count for much in the current reimbursement system, but that are crucial to the establishment of a medical home.

The first change that Dr. Baron's practice made, even before enrolling in the demonstration project, was the installation of an electronic medical records system. “It cost us $140,000 or $160,000 for a four-doctor group, and we didn't see any increased reimbursement from anybody for having made that investment.” But under the pilot, “there are points we get from the way we use the EMR that allow us somewhat to recoup the investment,” said Dr. Baron, who is also chair of the American Board of Internal Medicine.

Another change was the hiring of a “health educator” to develop systems to fulfill the NCQA guidelines that require patient involvement and education, Dr. Baron said. For example, the health educator has created action plans that remind the physicians to have conversations with diabetes patients about managing blood sugar and weight loss.

“Most of us in primary care know we're supposed to have those conversations, but most of us are so desperate to get through the day that … we don't. It's a workflow issue,” he said. And for those conversations to be reimbursed as part of an integrated medical home, they must be documented in the EMR system.

Greenhouse Internists is also increasing both the number of medical assistants and the number of non-clinically trained staff. “One of the things that you get when you start using the EMR is the ability to look [through the records] for the patients with poorly controlled diabetes whom you haven't seen in 6 months,” Dr. Baron said. “But once we've done that, it isn't obvious who is in the office to pick up the phone and call them.” In a traditional practice, the job would probably fall to the physician. “Doctors get into a pretty toxic spiral. … There isn't anyone to do it, so they do it themselves, and that's the worst answer, because we cost more than anybody.”

Non-clinically trained or nonphysician office staff are “underutilized” in primary care practices, he said. By hiring more nonclinical staff, Greenhouse can relieve physicians of tasks they would otherwise have to do.

In the meantime, Dr. Baron said he knows that the medical home movement is still only in the early stages.

“There's a lot of skepticism in the health care community about whether the patient-centered medical home is a flash in the pan. Is it going to go away?” he asked. And while practices like his participate in demonstrations, “the sad reality is that in a fee-for-service system, [non-visit-based care] takes the doctors off the fee-for-service treadmill, which is how they create income.”

Nevertheless, Dr. Baron is excited to be participating in the demonstration. “On the one hand, it's extra work for a group of people who are already pretty busy. But on the other hand, there's a sense of wonderful opportunity,” he said. “For us, this pilot is a way to recoup investments that we've already made, because we believe in a non-visit-based model of care.”

Eradication of Helicobacter pylori in patients with early-stage gastric cancer reduced the risk of subsequent metachronous gastric carcinoma significantly, compared with controls, in a Japanese study of more than 500 patients.

H. pylori is a known gastric carcinogen, according to the World Health Organization, and its causal effect on the development of gastric cancer has been proved in animal studies, noted the Japan Gast Study Group, which conducted the current study (Lancet 2008;372:392-7).

However, studies of the effect of eradication of the bacterium have had mixed results. Most notably, “a large-scale, double-blind randomized study in China showed that gastric cancer still occurred after successful eradication of H. pylori and that eradication did not lead to a significant decrease in the incidence of gastric cancer” (JAMA 2004;291:187-94).

In the current multicenter, open-label, randomized, controlled study of 544 patients with early gastric cancer who were either planning to have endoscopic treatment or who had just completed resection after endoscopic treatment, half of the patients (272) were given a drug regimen to eradicate the H. pylori bacterium, and half served as controls.

A modified intention-to-treat analysis included 255 patients in the treatment group and 250 patients in the control group, after 17 treatment patients and 22 controls were lost to follow-up. Three-quarters of patients in both groups were men, and all patients were aged 62–73 years.

The treatment group received a combination of lansoprazole 30 mg twice daily, amoxicillin 750 mg twice daily, and clarithromycin 200 mg twice daily for a week. All patients had follow-up clinic visits at 6 months, 1 year, 2 years, and 3 years after randomization, when they were examined endoscopically to see whether new cancer had developed. At these visits, participants also had their H. pylori status confirmed.

“During 3 years of follow-up after endoscopic treatment of primary gastric cancer, metachronous gastric cancer developed in 33 participants—9 in the eradication group and 24 in the control group,” wrote the authors, led by Dr. Kazutoshi Fukase of the department of gastroenterology at Yamagata (Japan) Prefectural Central Hospital. There were no differences between the patients who developed cancer in each group in terms of sex, age, location of the cancer, histologic type, or depth of the invasion of the diameter of the metachronous cancers. “The risk of subsequent cancer was reduced from about 4,000/100,000 individuals a year to 1,400/100,000 individuals a year.”

In an accompanying comment, Dr. Nicholas J. Talley of the department of internal medicine at the Mayo Clinic in Jacksonville, Fla., wrote, “The results are clear: in a high-risk population, gastric cancer rates are substantially reduced, but not abolished, by H. pylori eradication.” The potential risks associated with H. pylori eradication … are small, he added. “Preventing gastric cancer by eradicating H. pylori in high-risk regions should be a priority.”

Both the study authors and Dr. Talley declared that they had no conflicts of interest to disclose.

'Preventing gastric cancer by eradicating H. pylori in high-risk regions should be a priority.' DR. TALLY

Eradication of Helicobacter pylori in patients with early-stage gastric cancer reduced the risk of subsequent metachronous gastric carcinoma significantly, compared with controls, in a Japanese study of more than 500 patients.

H. pylori is a known gastric carcinogen, according to the World Health Organization, and its causal effect on the development of gastric cancer has been proved in animal studies, noted the Japan Gast Study Group, which conducted the current study (Lancet 2008;372:392-7).

However, studies of the effect of eradication of the bacterium have had mixed results. Most notably, “a large-scale, double-blind randomized study in China showed that gastric cancer still occurred after successful eradication of H. pylori and that eradication did not lead to a significant decrease in the incidence of gastric cancer” (JAMA 2004;291:187-94).

In the current multicenter, open-label, randomized, controlled study of 544 patients with early gastric cancer who were either planning to have endoscopic treatment or who had just completed resection after endoscopic treatment, half of the patients (272) were given a drug regimen to eradicate the H. pylori bacterium, and half served as controls.

A modified intention-to-treat analysis included 255 patients in the treatment group and 250 patients in the control group, after 17 treatment patients and 22 controls were lost to follow-up. Three-quarters of patients in both groups were men, and all patients were aged 62–73 years.

The treatment group received a combination of lansoprazole 30 mg twice daily, amoxicillin 750 mg twice daily, and clarithromycin 200 mg twice daily for a week. All patients had follow-up clinic visits at 6 months, 1 year, 2 years, and 3 years after randomization, when they were examined endoscopically to see whether new cancer had developed. At these visits, participants also had their H. pylori status confirmed.

“During 3 years of follow-up after endoscopic treatment of primary gastric cancer, metachronous gastric cancer developed in 33 participants—9 in the eradication group and 24 in the control group,” wrote the authors, led by Dr. Kazutoshi Fukase of the department of gastroenterology at Yamagata (Japan) Prefectural Central Hospital. There were no differences between the patients who developed cancer in each group in terms of sex, age, location of the cancer, histologic type, or depth of the invasion of the diameter of the metachronous cancers. “The risk of subsequent cancer was reduced from about 4,000/100,000 individuals a year to 1,400/100,000 individuals a year.”

In an accompanying comment, Dr. Nicholas J. Talley of the department of internal medicine at the Mayo Clinic in Jacksonville, Fla., wrote, “The results are clear: in a high-risk population, gastric cancer rates are substantially reduced, but not abolished, by H. pylori eradication.” The potential risks associated with H. pylori eradication … are small, he added. “Preventing gastric cancer by eradicating H. pylori in high-risk regions should be a priority.”

Both the study authors and Dr. Talley declared that they had no conflicts of interest to disclose.

'Preventing gastric cancer by eradicating H. pylori in high-risk regions should be a priority.' DR. TALLY

Eradication of Helicobacter pylori in patients with early-stage gastric cancer reduced the risk of subsequent metachronous gastric carcinoma significantly, compared with controls, in a Japanese study of more than 500 patients.

H. pylori is a known gastric carcinogen, according to the World Health Organization, and its causal effect on the development of gastric cancer has been proved in animal studies, noted the Japan Gast Study Group, which conducted the current study (Lancet 2008;372:392-7).

However, studies of the effect of eradication of the bacterium have had mixed results. Most notably, “a large-scale, double-blind randomized study in China showed that gastric cancer still occurred after successful eradication of H. pylori and that eradication did not lead to a significant decrease in the incidence of gastric cancer” (JAMA 2004;291:187-94).

In the current multicenter, open-label, randomized, controlled study of 544 patients with early gastric cancer who were either planning to have endoscopic treatment or who had just completed resection after endoscopic treatment, half of the patients (272) were given a drug regimen to eradicate the H. pylori bacterium, and half served as controls.

A modified intention-to-treat analysis included 255 patients in the treatment group and 250 patients in the control group, after 17 treatment patients and 22 controls were lost to follow-up. Three-quarters of patients in both groups were men, and all patients were aged 62–73 years.

The treatment group received a combination of lansoprazole 30 mg twice daily, amoxicillin 750 mg twice daily, and clarithromycin 200 mg twice daily for a week. All patients had follow-up clinic visits at 6 months, 1 year, 2 years, and 3 years after randomization, when they were examined endoscopically to see whether new cancer had developed. At these visits, participants also had their H. pylori status confirmed.

“During 3 years of follow-up after endoscopic treatment of primary gastric cancer, metachronous gastric cancer developed in 33 participants—9 in the eradication group and 24 in the control group,” wrote the authors, led by Dr. Kazutoshi Fukase of the department of gastroenterology at Yamagata (Japan) Prefectural Central Hospital. There were no differences between the patients who developed cancer in each group in terms of sex, age, location of the cancer, histologic type, or depth of the invasion of the diameter of the metachronous cancers. “The risk of subsequent cancer was reduced from about 4,000/100,000 individuals a year to 1,400/100,000 individuals a year.”

In an accompanying comment, Dr. Nicholas J. Talley of the department of internal medicine at the Mayo Clinic in Jacksonville, Fla., wrote, “The results are clear: in a high-risk population, gastric cancer rates are substantially reduced, but not abolished, by H. pylori eradication.” The potential risks associated with H. pylori eradication … are small, he added. “Preventing gastric cancer by eradicating H. pylori in high-risk regions should be a priority.”

Both the study authors and Dr. Talley declared that they had no conflicts of interest to disclose.

'Preventing gastric cancer by eradicating H. pylori in high-risk regions should be a priority.' DR. TALLY