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‘Our Voices, Our Lives’—A Report on Youth and STDs The prevalence of sexually transmitted diseases (STDs) in U.S. adolescents is widely underestimated, according to a panel of public health and other experts who looked at the economic impact and psychosocial burden of STDs in youth. In fact, sexually active teens have the highest STD rates of any age group. Half of an estimated 18.9 million new STD cases in 2000 were among youths ages 15 to 24, says a report issued in February by the School of Journalism and Mass Communication at the University of North Carolina at Chapel Hill. The report also indicates that STDs are so pervasive that one out of two sexually active young people can expect to become infected by age 25, with young women more at risk than young men because the infections can hide unnoticed in the female reproductive tract. The report, based on national studies by the Alan Guttmacher Institute and the Centers for Disease Control and Prevention, cites three diseases—human papillomavirus (HPV), trichomoniasis, and chlamydia—as accounting for 88 percent of new STD infections in the young. Incurable viral infections such as genital herpes, HIV, hepatitis B, and HPV are expected to account for most of an estimated $6.5 billion in STD-related lifetime medical costs. Among the troubling issues raised by those figures, the report points out, is that the rise of STDs in young people contrasts with a steady decline in teen birth and pregnancy rates in the 1990s. One explanation of the apparent inconsistency may be that young women are using efficient birth-control methods and products that prevent pregnancy but do not protect against disease. There also seems to have been a leveling-off of condom use in the late 1990s, which might account for an increase in STDs, according to Deborah Arrindell, senior director of health policy at the American Social Health Association. The Institute of Medicine notes that reported rates of STDs in the United States are the highest of any industrialized country, in part because of this country's reluctance to openly confront issues regarding sexuality and STDS, especially in the young. The Institute of Medicine has called the spread of STDs in the U.S. "a silent epidemic that had not reached the national agenda of public concern." Another factor is that many STDs are in themselves "silent," in that they cause few noticeable symptoms, especially in women, who are likely to have no symptoms until complications occur. No single test detects all STDs, but only testing can detect "silent" STDs in time for early treatment, the report points out. Why Young People? Young people in the age groups covered by the study are especially vulnerable to sexually transmitted diseases for a number of reasons, the report points out.
What to Do A consistent theme of recommendations made by young people who were invited to comment on the report was that everyone needs to talk more about STDs, including parents/guardians, teachers, health care providers, policymakers, and young people themselves. The young people urged, for example, that policymakers support comprehensive, science-based sex education "that includes information about abstinence and condoms" and programs that make condoms available to young people. The full text of the report on which this article is based, "Our Voices, Our Lives, Our Futures: Youth and Sexually Transmitted Diseases," is available online at www.jomc.unc.edu/youthandSTDs/ourvoicesrelease.html. Reports on STDs by the Alan Guttmacher Institute are available at www.guttmacher.org. Articles by researchers from the Centers for Disease Control and Prevention, "Sexually Transmitted Diseases Among American Youth: Incidence and Prevalence Estimates, 2000" and "The Estimated Direct Medical Cost of Sexually Transmitted Diseases Among American Youth, 2000," appear in the January/February 2004 issue of Perspectives in Sexual and Reproductive Health. ------------------------------------------- Separate SCHIP Programs Meet Needs of Special Children Children with special health care needs generally receive adequate or good health care coverage under the State Children’s Health Insurance Program (SCHIP) in the 36 states that have separate SCHIP programs, according to two reports prepared by the Maternal and Child Health Policy Research Center. The Center examined data from many sources to determine what health care would be available to children with any one of 12 chronic conditions—recurring otitis media, cerebral palsy and seizure disorder, spina bifida, sensory integration and motor planning dysfunction, asthma, multiple dental caries and malocclusion, anorexia nervosa, injuries from a motor vehicle accident, major depressive disorder with suicidal ideation, major depressive disorder, sexually transmitted disease, and substance abuse and bipolar disorder. Although the benefits under separate SCHIP programs were not as comprehensive and affordable as Medicaid SCHIP programs, separate SCHIP programs appear to offer far better insurance protection than most private health insurance plans, the Center found. "Overall, many states appear to have designed their separate SCHIP programs to meet the needs of children with chronic conditions and to be quite comparable to Medicaid SCHIP programs. With few exceptions, they have not, as many advocates feared, simply adopted conventional employer-sponsored health insurance benefit designs." "Overall, we found that certain children—primarily those with physical health conditions and those who did not require extensive therapy of any type—would have access to full coverage in the vast majority of separate SCHIP programs. This is because all states cover basic medical services, including physician services; inpatient and outpatient hospital services; laboratory and x-ray services; and medications. All cover outpatient mental health therapy on a short-term basis for diagnosed conditions such as major depressive disorder, and nearly all cover ancillary therapy services on a short-term basis for acute care and rehabilitative purposes. Also, annual preventive visits and semi-annual dental exams are covered in nearly all states, as are non-oral contraceptives." The two areas in which coverage was most variable, the study found, were complex mental health or developmental problems and dental problems—many of the states set limits on mental health coverage, and dental benefits often do not include orthodontia. Since SCHIP is a program aimed at insuring children from relatively low-income families, cost sharing (how much of the cost of care a family is expected to assume) can be a major problem. The study found wide variability in both premiums and co-payments, with total out-of-pocket costs greater for families with incomes at 186 percent of poverty than for families with incomes at 151 percent of poverty. Generally, the extent of cost sharing by families did not vary much by the children’s conditions or service requirements. The report cautions that as states consider changes in SCHIP in light of fiscal problems, they will have to answer some pressing questions. For example,
In addition to those questions, states will need to take note of and decide how to handle "the erosion that is rapidly taking place in the employer-sponsored health insurance market," which could make it increasingly difficult for families to obtain the special care they need for special needs children. Two reports by the Maternal and Child Health Policy Research Center, "Separate SCHIP Programs: Generous Coverage for Children with Special Needs in Most States," and "Eligibility, Benefits, and Cost-Sharing in Separate SCHIP Programs," are available online at www.mchpolicy.org. Editor’s Note: By law, states may choose to implement SCHIP either by creating separate SCHIP programs or by expanding coverage under Medicaid. The programs referred to in this article are separate SCHIP programs. Such programs are allowed to set more restrictive or less restrictive eligibility and coverage requirements than Medicaid does. ------------------------------------------- Why Did a Highly Vaccinated School Population Come Down with Chickenpox? Researchers reporting in the March 2004 issue of the journal Pediatrics confessed to being puzzled about a 2001 outbreak of chickenpox in an Oregon elementary school that had achieved a 97 percent vaccination rate. The outbreak happened after public schools began phasing in a varicella vaccination requirement for enrollment. Chickenpox was a nearly universal disease of childhood until the pharmaceutical company Merck gained Food and Drug Administration approval for a vaccine in 1995. Varicella immunization is now recommended for infants at 14 or 15 months age, and for older children who’ve never had chickenpox. Oregon began requiring varicella vaccination for children attending day care and kindergarten, and seventh graders with no history of chickenpox, in September 2000. At the time of the elementary school outbreak in 2001, 218 of 422 students in the school (grades kindergarten through 6) had never had chickenpox, and of these, 211 or 97 percent had been vaccinated. Despite that high level of vaccination, 22 cases of chickenpox occurred in nine classrooms in the school, most of them in children who had been vaccinated. It’s always hard to predict how a new vaccine will work out, and there hasn’t been time yet to know how long immunity will last after varicella vaccination, or whether booster shots will be necessary. Clinical trials in the United States before the vaccine was approved seemed to show immunity persisting for 6 to 10 years after vaccination, and similar trials in Japan had documented immunity for up to 20 years, but outbreaks such as the one in Oregon raise new questions, the researchers concluded. One of the possibilities is "vaccine failure"—many factors, including where a vaccine was stored and administered, or whether there might have been a "bad lot"--might explain loss of vaccine potency. In the Oregon case, students had been vaccinated in a variety of clinics with multiple vaccine lots, making the "bad lot" theory less likely. But whatever the cause, the researchers concluded that "Our finding is suggestive of waning immunity." They are now investigating other reported outbreaks of chickenpox in Oregon, to try to determine what factors might be contributing to "waning immunity," including how long it had been since a child was vaccinated. "If the interval between vaccination and exposure is significantly associated with breakthrough disease in future outbreak investigations, routine booster vaccination for children might be warranted." But even if "breakthrough" cases do occur, the researchers pointed out, "several benefits of vaccination are noteworthy." For one thing, surveillance has shown that there are many fewer cases of chickenpox, overall, since the vaccine was introduced. And if cases do occur, the illness is usually milder than wild-type chickenpox; this was true in the Oregon school, where vaccinated children who came down with chickenpox had fewer lesions than would have been expected in unvaccinated persons. The research report, "Chickenpox Outbreak in a Highly Vaccinated School Population," appeared in the March 2004 issue of the journal Pediatrics. Requests for reprints should be addressed to paul.r.cieslak@state.or.us. ------------------------------------------- New Congress Addresses Health Issues Healthy Choices for Healthy Children In a series of hearings to prepare for reauthorization of the Child Nutrition Act and re-examination of the National School Lunch Act this year, the Subcommittee on Education Reform of the House Committee on Education and the Workforce February 12 heard advocates for sports and physical education describe the effects of inactivity on overweight or obesity in children. Judith Young, vice president of the American Alliance for Health, Physical Education, Recreation and Dance, noted that poor eating and inadequate physical activity combined account for a tripling in the past 20 years of the number of overweight or obese children. "The old adage of ‘a sound mind in a sound body’ is even more compelling in our modern society, where we have engineered physical activity out of our lives and where ‘super-sized fast food’ allows us to easily consume more calories than we need or spend," Young said. Introducing the February 12 hearing, Delaware Representative Michael Castle, chair of the Subcommittee on Education Reform, promised that the Education Committee "will address the battle against childhood obesity in the context of the child nutrition reauthorization." "As the Committee seeks to improve child nutrition programs and address the important and complex issue of childhood obesity during reauthorization, we will examine the available science and take into consideration all factors known to contribute to obesity, while supporting the role of local school districts to make decisions about foods and activities that are available to children in school," Castle said. "Over the past several years, schools and programs providing meals and snacks to children have made progress in improving lunch menus to meet federal nutrition standards for fat and calories, but I believe more can be done …" Castle has introduced a bill, H.R.2227, the Childhood Obesity Prevention Act, which would authorize state and local grants for pilot programs to promote healthful eating and physical activity among children. Rising Health Costs and the Uninsured The Senate Committee on Health and Education held a hearing late in January to discuss rapidly rising health care costs and the significant number of Americans without health insurance, both of which are "serious problems that have grave economic and social implications for the U.S.," according to the committee chairman, Senator Judd Gregg (R-NH). Committee member Bill Frist, the U.S. Senate Majority Leader, noted that the number of Americans without health coverage is now more than 43 million, at the same time that health care costs for two straight years grew faster than the rate of growth of the gross domestic product, reaching $1.6 trillion. "Clearly, these trends are related, and they must be examined, and addressed, simultaneously," Frist said. Committee member Senator Tom Harkin (D-IA) noted that chronic diseases account for roughly 75 percent of the nation’s health care costs each year, "and most are preventable." Harkin cited an annnual cost of $352 billion for cardiovascular disease, $117 billion for obesity, $132 billion for diabetes, more than $75 billion for smoking-related illnesses, and $79 billion for untreated mental illness. "If we are to bring down health care costs, we must give people access to preventive care, and give them the tools they need to stay healthy," Harkin said. He indicated that he will be introducing legislation to address the risk factors associated with chronic disease, focusing on nutrition, physical activity, and obesity; mental health; and tobacco cessation. The ranking Democrat on the committee, Senator Ted Kennedy (D-MA) was critical of administration proposals for refundable tax credits to help low-income families afford the cost of insurance, saying those credits are "far too small to allow most low-income families to afford real coverage." The Institute of Medicine told the Senate committee that any health insurance plan it comes up with should be:
That could be achieved in at least four different ways, the Institute said—by requiring employers to provide health insurance, with subsidies for employers of low-wage workers; or by combining Medicaid and SCHIP and extending Medicare to 55-year-olds; or by eliminating Medicaid and SCHIP and requiring individuals to buy their own coverage, with tax credits; or by setting up a "single payer," federally administered and funded, and eliminating Medicaid, SCHIP, and Medicare. The Senate is not expected to pass any health insurance reform until after the November elections. ------------------------------------------- Worth Noting ‘Green Hornet’ Is Dangerous Alternative to Ecstasy A liquid substance known on the street as "Green Hornet" has sent teenagers to hospital emergency rooms with seizures, excessive heart rates, severe body rashes, and high blood pressure, according to the federal Food and Drug Administration (FDA), which is warning that the substance, promoted on the Internet and sold in stores as an herbal alternative to the street drug "Ecstasy," contains the active ingredients diphenhydramine and dextromethorphan, which are found in over-the-counter cough/cold medications. The product comes in 4-ounce and 16-ounce bottles that do not bear the name of the manufacturer, and the FDA is warning that the substance, like others marketed as alternatives to street drugs, may be abused by minors. New Guidelines for Intakes of Water, Salt, Potassium The Food and Nutrition Board, which monitors and recommends the intake of nutrients by Americans, recommended in February that thirst should determine how much water people drink, not exact requirements such as the popular eight glasses a day. The Board noted that about 80 percent of total water intake comes from water and beverages, and the other 20 percent from food. The tolerable upper intake level (UL) for salt is set at 5.8 grams per day, and most Americans consume more than that, the Board said. On another nutrient—potassium, which blunts the effects of salt and reduces the risk of high blood pressure—the Board noted most Americans consume about the recommended daily amount of 4.7 grams. Nasal Flu Vaccine Failed to Catch On Even when there was a shortage of the familiar injected flu vaccine during this year’s flu season, people shied away from a nasal spray that’s equally effective at warding off the flu, the manufacturer of the alternative FluMist told a congressional committee in February. Medimmune, a biotechnology company that spent more than a billion dollars developing FluMist, will have to destroy as many as 4 million of the 5 million doses it produced for the 2003-2004 season, since flu vaccines have to be reformulated every year as strains of the virus change. It appears, Medimmune said, that health workers, in particular, were concerned that if they took the nasal vaccine, which contains live but weakened influenza viruses, they might give off the virus to patients with compromised immune systems. Noting the "incredibly difficult regulatory landscape of bringing new and more effective vaccines to market," including stringent safety and efficacy standards that older medications were never required to meet, Medimmune said it’s trying to decide whether to "cut its losses and get out now" or stay in the vaccine business. February News Alerts The following information appeared during the month of February in the News Alerts section of this website. Web Site Aims to Educate Kids about Calcium As part of a campaign to increase children’s and adolescents’ awareness of the importance of calcium in their diets, especially in the bone-growth years from 12 to 19, the National Institute of Child Health and Human Development is introducing a new series of games on its "Milk Matters" website. In addition to games, the Web site, www.nichd.nih.gov/milk/kidsandteens offerd free items including booklets, fact sheets, coloring books, stickers, and posters, most available in both English and Spanish, all intended to support the campaign’s message that low-fat or fat-free milk is an excellent source of dietary calcium, as well as vitamins D, A, and K; riboflavin; B12; potassium; magnesium; and protein, all essential to healthy bone and tooth development. There’s also a "spokescow"—Bo Vine, an energetic Holstein who love milk and is featured in many of the mazes, puzzles, and decoders. Information about the calcium campaign in general is available to health professionals at www.nichd.nih.gov/milk. NASBHC Cites Congressional Encouragement for School-Based Health Centers The National Assembly on School-Based Health Care (NASBHC) noted that a conference report for the 2004 appropriations bill for Health and Human Services (HHS) includes language urging the Health Resources and Services Administration (HRSA) to make school-based health centers eligible for federal funding under Section 330 of the Public Health Service Act. "Recognizing the contributions that these entities have made in their respective communities, the conferees strongly urge HRSA to make these previously funded programs eligible for funding in 2004," the conference report reads. Calling this a "small but important victory" for school-based health centers, NASBHC director John Schlitt pointed out that Senators Arlen Specter (R-PA) and Tom Harkin (D-IA) were instrumental in having support for SBHCs included in the conference report. Their action came in response to decisions by HRSA last year that made school-based entities ineligible for funding under the agency’s community-based health centers program. "We’ll be working with our congressional supporters to follow up on HRSA’s response," Schlitt promised. SCHIP Covered 5.8 Million Children in 2003, HHS Reports About 5.8 million children who otherwise would have had no health insurance were enrolled in the State Children’s Health Insurance Program (SCHIP) at some time during the year 2003, according to statistics released February 12 by the Centers for Medicare and Medicaid Services (CMS), which administers SCHIP. This was an increase of 9 percent from the previous year, CMS said. SCHIP, created in 1997, is a state/federal partnership designed to provide health insurance coverage to uninsured children, many of whom come from working families with incomes too high to qualify for Medicaid but too low to afford private health insurance. SCHIP enrollment by states will be available at www.cms.gov/schip/enrollment. Life Expectancy, Infant Mortality Rose in 2002, NCHS Reports Both the number of years most Americans lived and the number of babies who died soon after birth rose in 2002, compared to 2001, according to preliminary statistics released February 11 by the National Center for Health Statistics (NCHS). Infant mortality, already high in the United States compared with other developed nations, increased from 6.8 infant deaths per 1,000 live births to 7 deaths per 1,000 live births, with most of the deaths occurring in neonates (infants less than 28 days old) and in the first week of life. Factors contributing to infant deaths, the NCHS said, were congenital anomalies (birth defects), disorders related to short gestation and low birthweight, and maternal complications of pregnancy. "Factors such as low birthweight, preterm births, and multiple births all increase the risk of infant death," said NCHS director Edward Sondik. At the other end of life, Americans lived to be an average 77.4 years of age in 2002, up from 77.2 years in 2002, with both men and women and African-Americans and whites benefiting from greater longevity. The reports, "Deaths: Preliminary Data for 2002," and "Supplemental Analyses of Recent Trends in Infant Mortality," are available online at www.cdc.gov/nchs. CDC Asks Delay in Final Dose of Pneumococcal Vaccine The Centers for Disease Control and Prevention (CC) recommended February 13 that doctors delay giving children the fourth and final dose of the pneumococcal conjugate vaccine Prevnar because of shortages resulting from production problems at the only manufacturer of the vaccine in the United States. The vaccine is normally given to infants at 2, 4, and 6 months, with a booster shot at ages one to five years. The CDC is now recommending that the booster shot be postponed for healthy children until the vaccine shortages are resolved, possibly next summer. The vaccine, PCV7, has sharply reduced the incidence of invasive pneumococcal disease among children under two years of age since it was recommended for routine use in 2000. Updates on the current vaccine shortage are available at www.cdc.gov/nip/news/shortages. Bird Flu Being Watched for Possible Human Transmission The Centers for Disease Control and Prevention (CDC) reported February 13 that so far as is now known, the avian or bird influenza that is causing illness and deaths in China, Thailand, and other Asian countries is being transmitted to humans from wild and domesticated birds, but is not passing from humans to humans. The CDC warns, however, that if "genetic reassortment" of the virus should take place, the likelihood of humans infecting humans will increase. At the present time, the CDC recommends that state and local health departments, hospitals, and clinicians "enhance" their efforts to identify patients who may be infected with the influenza A (H5N1) virus and take control measures when infection is suspected. Indicators of infection may include coughing, sore throat, shortness of breath, or pneumonia or other respiratory conditions for which an alternative diagnosis has not been established. Also, patients should be asked if they have traveled within 10 days of reported symptoms to a country with documented H5N1 avian influenza infections in poultry or humans, or have had any contact with a poultry farm, a household raising poultry, or a known or suspected patient with avian influenza. Respiratory specimens from patients meeting those indicators should be sent to the CDC for testing. Requests for testing should come through local and state health departments, who are asked to contact CDC’s Emergency Operations Center by telephone at 770-488-7100. FDA Warns about Counterfeit Drugs The federal Food and Drug Administration (FDA) February 18 released a report outlining the steps the agency plans to take to stem a growing threat from counterfeit drugs that are being imported into the United States or marketed on unregulated Internet websites. The FDA charged that well organized criminal organizations are working to introduce finished drug products that closely resemble legitimate drugs but may contain only inactive or incorrect ingredients or be otherwise contaminated. The report urges consumers to report if they encounter counterfeit drugs but does not explain how to recognize a counterfeit. The report says, however, that the FDA will take steps to protect consumers, including using new technologies to protect legitimate drugs against tampering or replacement with counterfeits. FDA Requires Bar Codes on Drugs The federal Food and Drug Administration (FDA) has published regulations that will require drug manufacturers to include linear bar codes on all prescription medications and many over-the-counter drugs, as a way of preventing dosage and medication errors. The machine-readable codes, similar to those on thousands of consumer products, must contain, at a minimum, the drug’s National Drug Code number, and they may also contain information about lot number and product expiration dates. The FDA says widespread adoption of bar codes is expected to reduce medication errors in hospitals and other dispensaries by requiring nurses and others who give medications to scan a patient’s bar code to verify that the right medication, in the correct amount and formulation, is being given. The FDA’s final rule, published in the Federal Register February 25, applies to most drug manufacturers, repackers, relabelers, private label distributors, and blood establishments. New medications will have to have bar codes within 60 days of their approval, and most previously approved medicines and all blood and blood products must comply with the new requirements within two years.
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