GAO Says Law Requires Information on Condoms in Abstinence Education The federal Government Accountability Office (GAO), the investigative arm of Congress, told the Department of Health and Human Services (HHS) October 18 that abstinence education materials that do not contain "medically accurate information about condom effectiveness" are in violation of a provision of the Public Health Service Act. The GAO did not identify which abstinence education materials prepared and used by federal grantees may be violating the law, but the agency advised HHS to "reexamine its position" on how condoms are to be discussed in federally funded sex education programs. The issue came up during a GAO investigation of abstinence education grants requested by members of Congress, after charges surfaced in recent years that abstinence-only sex ed programs funded by the federal government refer to condoms negatively and discourage their use. In a letter to Secretary of Health and Human Services Michael Leavitt, GAO General Counsel Gary Kepplinger said that in the course of its investigation, the GAO noted language in section 317P(c)(2) of the Public Health Service Act requiring that materials "that are specifically designed to address sexually transmitted diseases" must contain medically accurate information on condom effectiveness. That’s not how HHS is interpreting the law in its guidelines for abstinence-only education, the GAO pointed out. Currently, HHS takes the position that, while grantees may address issues related to sexually transmitted diseases in communicating the importance of abstinence, the programs are not primarily intended to address sexually transmitted disease, and therefore section 317P(c)(2) doesn’t apply. Calling the HHS argument "not persuasive," the GAO noted that the 2006 program announcement for community-based abstinence education programs instructs grantees to develop curricula around themes and further instructs them to "incorporate material around the subtheme of sexually transmitted diseases." The announcement offers illustrations of the use of disease-specific information and says abstinence-only programs may contain information on the limitations of contraception to consistently prevent sexually transmitted diseases, as well as information on the epidemiology of sexually transmitted disease in the United States. That is enough to bring abstinence-only education programs under SectionP(c)(2), the GAO said, and requires the programs to "include medically accurate information on condom effectiveness." "In light of our conclusion, we recommend that HHS reexamine its position and adopt measures to insure that, where applicable, abstinence education materials comply with this requirement," the GAO said. The GAO letter to Secretary Leavitt, "Abstinence Education: Applicability of Section 317P of the Public Health Service Act," is available online at http://www.gao.gov. Condom Use by Adolescents Noting that approximately 18.9 million new cases of sexually transmitted infections occur every year in the United States, half of them among 15-to-24-year-olds, researchers set out last year to test whether lack of condom use increased the risk of two of the most common infections—Chlamydia trachomatis and Neisseria gonorrhoeae—in a group of sexually active adolescent girls. In the study, non-pregnant, HIV-negative girls 13 to 19 years old received physical examinations and were administered questionnaires on condom use as well as information about their partners, sexual and reproductive peer norms, alcohol use, and self-esteem. The study evaluated the relationship between self-reported "correct and consistent" condom use and chlamydial and gonococcal infection in the group of high-risk girls. Reporting their findings, the researchers said correct and consistent use of condoms reduced the risk of gonorrhea and chlamydia by 90 percent, leading the researchers to conclude that "condoms remain the best STD and HIV prevention approach for adolescents whose sexual behaviors place them at risk for STDs. Although messages directed at adolescents encourage delaying initiation of sexual activity, many are already sexually active, and STDs are particularly common among this group. Thus, aggressive condom promotion must remain a key to reducing STDs and HIV." The research report, "The Effect of Correct and Consistent Condom Use on Chlamydial and Gonococcal Infection Among Urban Adolescents," was published in the June 2005 issue of the journal Archives of Pediatrics and Adolescent Medicine. Most states report to the Centers for Disease Control and Prevention (CDC) every year on the vaccine coverage of children entering kindergarten, including how many children are immunized against diseases such as hepatitis B, diphtheria, tetanus, pertussis, polio, measles, rubella, varicella, and mumps. State laws requiring proof of vaccination at school entry have been considered a safety net assuring that no child in the United States will be missed. The safety net relies on schoolteachers, health department staff, and others to identify children who are not up-to-date with their vaccinations. "Findings of nationwide coverage in recent years underscore the success of school entry requirement vaccination coverage, which increased substantially when entry requirements were established," the CDC said in a report on vaccination coverage in the 2005-2006 school year. But the goal of universal coverage may be harder to realize in the future, as more and more states offer nonmedical exemptions to the vaccination requirement, say researchers who looked into the effects of exemptions on one particular disease—pertussis—which remains endemic in the United States and has been increasing during the past decade. The researchers point out that at one time, parents were required to show that they held and practiced religious beliefs that prevented vaccination of their children. Increasingly, however, states—19 as of March 2006--are allowing "personal belief" exemptions, which can include philosophical or other unspecified nonmedical reasons for refusing vaccination. In some states, such as Maryland and California, personal belief exemptions are very easy to obtain, requiring only a parental signature on a preprinted statement. Other states have some administrative requirements, such as notarization or a personal appearance or letter by the parent. To try to determine the effect of nonmedical exemptions in general and "personal belief" exemptions in particular, the researchers analyzed state-level exemption rates for school years 1991-92 through 2004-05. In those years, all states except Mississippi and West Virginia allowed religious exemptions, and 19 allowed "personal belief" exemptions. Using a complex research model, the investigators examined school data on the disease of primary interest to them—pertussis. What they found was that states where personal belief exemptions exist and are easily obtained had higher exemption rates and greater incidence of pertussis than those with religious exemptions only. Pertussis incidence in states allowing personal belief exemptions was more than twice as high as in states that allowed only religious exemptions. States with easy procedures for granting personal belief exemptions had a 90 percent higher incidence of pertussis. "These study findings indicate that state exemption policies affect exemption rates as well as pertussis incidence," they said. Because children with exemptions from vaccination are at increased risk of disease and more likely to communicate disease to others, states may need to take another look at their immunization policies, on public health grounds, the researchers suggested. "State-level policies on nonmedical exemptions and documentation of immunization status should be viewed as part of the efforts to control or eliminate vaccine-preventable diseases." The research report, "Nonmedical Exemptions to School Immunization Requirements," appeared in the October 11, 2006, issue of the Journal of the American Medical Association. The corresponding author can be contacted at das@ehpr.ufl.edu. The CDC report on vaccination coverage in 2005-06 can be read at http://www.cdc.gov/mmwr/, October 20, 2006. See also: "The Politics of School Immunization" at http://www.healthinschools.org/ejournal/2005/may1.htm and "Are Schools a Factor When Parents Refuse Immunization?" at http://www.healthinschools.org/ejournal/2004/july3.htm. An Update on Preventing Meningococcal Disease in AdolescentsA death from meningococcal disease, occurring as it often does in otherwise healthy adolescents, is devastating to the family and the community and elicits strong demands for preventive measures, according to an article in the October 5 issue of the New England Journal of Medicine. To help with answering those questions and others, Gardner sketches what is known about invasive meningococcal disease.
Two meningococcal vaccines are licensed for use in the United States. Both provide antigens against serogroups A, C, Y, and W-135, but unfortunately neither protects against serogroup B, which is responsible for one-third of cases. One of the vaccines, Menomume, made by Sanofi Pasteur, has been available for 25 years. The vaccine is considered safe but has some limitations—the duration of protection is short (three to five years in adolescents and adults). It’s sometimes recommended for persons needing short-term protection--travelers to regions where the meningococcal disease is endemic, for example. The second vaccine, Menactra, also made by Sanofi Pasteur, was approved in January 2005 for use in persons 11 to 55 years of age. It contains the same antigens as the earlier vaccine, plus diphtheria toxoid. It’s expected to provide more durable protection than the earlier vaccine and to be more effective in establishing herd immunity. The Advisory Committee on Immunization Practices now recommends that all adolescents be immunized with the newer vaccine, beginning with children 11 to 12 years of age, with a catch-up immunization at the time of high school entry for persons not previously vaccinated. Dr. Gardner notes that if the strategy of vaccinating all children 11 to 12 years of age were fully implemented, plus the high school catch-up, everyone 11 to 19 years old would be immunized by the year 2008 against meningococcal disease caused by subgroups A, C, Y, and W-135. Protecting Contacts The question immediately confronting schools and public health officials when a case of meningococcal infection is identified is how to keep one case from becoming an outbreak. "The most urgent priority," Dr. Gardner writes, "is to treat the patient’s close contacts with an effective antimicrobial agent." The CDC maintains a list of recommended antimicrobials for use in that situation. The definition isn’t precise, but "close contact" does not include classmates or co-workers, unless they were in close proximity (three feet or less) to the patient for eight hours or more, or were directly exposed to the patient’s oral secretions through kissing, mouth-to-mouth resuscitation, or management of an endotracheal tube. More likely to be close contacts are members of the patient’s household, roommates, and anyone who sat next to the patient on an airplane for more than eight hours. Summing up, Dr. Gardner notes that challenges to creating a comprehensive immunization program for meningococcal disease include the lack of serogroup B coverage in current vaccines, difficulties in reaching adolescent populations, and vaccine shortages. But he suggests that the anxiety caused by even one case "provides an opportunity to promote community compliance with current recommendations." Editor’s note: There are two forms of meningitis, one caused by bacteria and the other viral. Dr. Gardner’s article deals with the bacterial form. Viral meningitis, a less severe form of the illness, is often mistaken for the flu; patients normally recover in a week or so without treatment. The article "Prevention of Meningococcal Disease" was published in the October 5, 2006, issue of the New England Journal of Medicine, which can be reached at http://content.nejm.org. Health Care Seen as Second-Tier Issue in November ElectionsAmericans are worried about the cost of health care and the rising numbers of people with no health insurance, but those are not the top issues for government action as national elections near, according to the policy journal Health Affairs. Opinion surveys conducted in 2006 found most Americans don’t think the health care system is in crisis, although there is a lot of dissatisfaction with both health care and the public health system. As a top-level public concern, health has been topped by current issues such as immigration, the war in Iraq, and the price of gasoline, though it remains one of the long-range issues the public is most likely to cite in polls, along with education, terrorism, crime, Social Security, and the environment, especially global warming. "Issues such as health care that are a part of people’s everyday lives remain enduring concerns in poll findings," Health Affairs notes. To try to present a comprehensive picture of the public’s health priorities in 2006, and the changes that have taken place over time, the paper analyzed polling results from 19 national opinion surveys conducted between 1940 and 2006, with particular attention to trends since the time of the Clinton health reform plan in the early 1990s. Some of the findings:
Commenting on the poll results this year, Health Affairs said that although most Americans don’t think the health system is in crisis, the public remains dissatisfied with the country’s health care and public health systems. "These attitudes are likely to create a climate supportive of both increased health spending and substantial changes in the years ahead," the paper concluded. The report "Understanding the American Public’s Health Priorities: A 2006 Perspective," appeared as a Web Exclusive on October 17, 2006, in the online edition of the September-October issue of Health Affairs. Worth NotingHHS Promises Physical Activity Guidelines Speaking to a Prevention Summit in Washington, DC, October 26, Secretary of Health and Human Services (HHS) Mike Leavitt said the department is developing "comprehensive guidelines drawn from science" to help Americans fit physical activity into their lives. The guidelines, to be issued in late 2008, will "underscore the importance of physical activity to America’s health and assist on the journey to a healthier life," Leavitt said. The Prevention Summit is an annual HHS-supported event intended to highlight successful initiatives in disease prevention and health promotion. Innovation in Prevention awards made at the summit included an elementary school obesity prevention program managed by the University of Texas School of Public Health and the Alhambra United School District Nutrition Network program, a California program that aims to overcome barriers to a healthy diet. See also: "Experts Cite Physical Activity as Key in Preventing Childhood Obesity" at http://www.healthinschools.org/ejournal/2005/dec2.htm and "Keeping Kids Healthy: Overweight, Nutrition & Physical Exercise" at http://www.healthinschools.org/sh/obesity.asp. -----------------------------------Mumps Clusters Reported on College Campuses From May to September this year, mumps clusters have been reported on college campuses in Illinois, Kansas, and Virginia, according to the Centers for Disease Control and Prevention (CDC). Ninety-six percent of the cases occurred in persons who had received two doses of MMR vaccine, indicating that mumps-containing vaccines are not 100 percent effective, the CDC said. The CDC urged health care providers to remain alert for suspected mumps cases and to conduct appropriate testing. For school-age children, evidence of immunity to mumps is now defined as one dose of live mumps vaccine. Additional recommendations for outbreak control include administering an additional dose of the vaccine. The CDC’s Brief Report on mumps, dated October 27, 2006, is available at http://www.cdc.gov/mmwr The following information appeared during the month of October 2006 in the News Alerts section of the website of the Center for Health and Health Care in Schools, at www.healthinschools.org. October 4, 2006Nurses Who Assign Duties Are Supervisors, Labor Board Rules Nurses who exercise "independent judgment" when they assign "significant overall duties" to other employees are supervisors, the National Labor Relations Board (NLRB) ruled October 3. The ruling would exempt registered nurses who supervise the work of others from union membership if they oversee other employees just 10 to 15 percent of their total worktime. The NLRB issued its rule after the United States Supreme Court ruled in 2001, in a case involving nurses in an acute care facility in Michigan, that the Labor Board had previously been too strict in deciding who is a supervisor. Labor experts predicted that yesterday’s ruling could affect as many as 8 million workers, possibly including teachers who supervise aides, as well as nurses. The ruling is onsite at www.nlrb.gov. October 6, 2006FDA Updates E.coli Search In a statement released October 5, the federal Food and Drug Administration (FDA) conceded that it does not yet know the source of E.coli infection that has caused sickness and death in persons who ate spinach grown in California, but the FDA said it is continuing to examine factors such as the water used in growing or processing spinach, the "environment" in which it is grown and processed, and whether animal wastes are involved. To date, the FDA has received reports of 192 cases of illness due to E.coli, with 30 cases of Hemolytic Uremic Syndrome, 98 hospitalizations, and two deaths. Epidemiological and laboratory evidence obtained so far traces the current outbreak to spinach grown by one large company in central California, but there is a long history of E.coli from leafy greens grown in the region, the FDA said. The statement said that at the present time, any plans developed as part of a long-term strategy for minimizing the risk of another outbreak will be voluntary, though the statement emphasized that both the FDA and the state of California "are not excluding the possibility of regulatory requirements in the future." Further updates on the current investigation will be available at www.fda.gov. October 10, 2006 The federal Food and Drug Administration announced October 6 that it has approved the adult antipsychotic drug Risperdal (risperide) in tablet form for symptomatic treatment of irritability in autistic children and adolescents. Steve Galson, director of the FDA’s Center for Drug Evaluation and Research, noted that Risperdal is "a welcome addition" to the growing number of adult drugs that have been shown to have "an appropriate risk-benefit profile" when tested in children. Risperdal has been in use since 1993 for short-term treatment of adults with schizophrenia and since 2003 for short-term treatment of adults with acute manic episodes associated with extreme mood swings. The drug was tested for safety and effectiveness in children in placebo-controlled trials involving children 5 to 12 years old, the FDA said. Risperdal is the first drug ever approved to treat behaviors generally referred to as irritability in children with autism, which may include aggression, deliberate self-injury, and temper tantrums. Risperdal is marketed by Janssen, L.P., of Titusville, NJ. October 11, 2006A Status Report on Electronic Health Records The most comprehensive study to date of the extent to which doctors and hospitals are using electronic health records (EHRs) has found that only one in four doctors use EHRs to improve how they deliver care to patients, and fewer than one in ten uses what experts define as a fully operational system, meaning a system that collects patient information, displays test results, allows providers to enter medical orders and prescriptions, and helps doctors make treatment decisions. The study released today, "Health Information Technologies in the United States: The Information Base for Progress" finds technology adoption rates low because of multiple financial, technical, and legal barriers. "We are pitifully behind where we should be," said study co-author Dr. David Blumenthal. "We must find ways to get more physicians to embrace this technology if we are to make major strides in improving health care quality." The full text of the report, a joint project of the Robert Wood Johnson Foundation and the federal government’s National Coordinator for Health Information Technology, is available online at www.rwjf.org. A companion article highlighting key findings of the report is published in the October 1 web edition of the journal Health Affairs at http://content.healthaffairs.org/cgi/content/abstract/hlthaff.25.w496 October 13, 2006EPA Reports on Environmental Risks to Children In a comprehensive report released today, the federal Environmental Protection Agency (EPA) details a framework for "a complete and transparent assessment of exposure of environmental agents to children and resulting potential health risks." The EPA says the report lays out a life-stage-specific process for assessing environmental risks and includes web links to specific online publications and scientific papers. The document will be available electronically beginning today through the website of EPA’s National Center for Environmental Assessment at http://www.epa.gov/ncea. October 13, 2006Many Teens Use Tanning Devices Despite Warnings Almost 10 percent of females ages 14-17 told a national health survey that they use tanning devices such as sunlamps and tanning beds, even though the World Health Organization has warned against the use of such devices by persons under 18 because of the risk of skin cancer. The National Health Interview Survey found girls seven times more likely than boys in the same age group to use artificial tanning, but in both groups, usage increased with age, peaking at age 17. In announcing the survey findings today, the CDC repeated an earlier recommendation that schools should advise students of the dangers of artificial tanning devices as part of programs to prevent skin cancer. The results of the National Health Interview Study are available at http://www.cdc.gov/nchs/nhis.htm. October 16, 2006 A report on foods available in schools that was scheduled to be released this month will not be available until January 2007, according to the Institute of Medicine. A multidisciplinary committee has held public meetings and surveyed the literature on foods and beverages offered outside the federally reimbursed school lunch and breakfast programs and is considering whether a single set of nutrition standards for such foods is appropriate for elementary, middle, and high schools. The report now due in January is expected to make recommendations for nutrition standards "to assure that foods and beverages offered in schools contribute to an overall healthful eating environment." The report is also expected to develop benchmarks to guide future evaluation studies of the application of the standards. The study is being supported by the federal Centers for Disease Control and Prevention. October 19, 2006Report Urges Attention to Children’s Exposure to Radiation, Chemicals When communities and school districts choose sites for schools near cleaned-up toxic waste sites or other sources of radiation or chemicals, they are relying on an outdated measure of the health risks posed to children by such environmental hazards, according to a report released today by a coalition of scientists, physicians, cancer prevention specialists, children’s health organizations, and women’s groups. In an open letter to President Bush, the Institute for Energy and Environmental Research urged a shift of federal regulations from measuring environmental effects on adult males—the current "Reference Man" —to more comprehensive exposure standards that include children. Currently, "Reference Man" is officially defined internationally as being between 20 and 30 years of age, weighing 70 kg (154 pounds), 170 centimeters (5 feet 7 inches) tall, living in a climate with an average temperature of between 20 and 30 degrees centigrade, and "a Caucasian and Western European or North American in habit and custom." That standard is widely used to decide, for example, how much residual radiation will be allowed in radioactively contaminated soil, where a new power plant will be built, or how much medical radiation an individual can safely receive. But the Reference Man criterion leaves out an awful lot of people, especially children and women, the Institute points out, which is important because children and women, especially those who are pregnant or nursing, are especially vulnerable to environmental toxins. The Institute reminds the President that he signed an executive order on protecting children from environmental hazards three years ago, which acknowledges that children are "disproportionately vulnerable to environmental hazards." Information about the Institute’s report, "Science for the Vulnerable: Setting Radiation and Multiple Exposure Environmental Standards to Protect Those Most at Risk," is available at http://www.ieer.org. October 19, 2006Report Urges Attention to Children’s Exposure to Radiation, Chemicals When communities and school districts choose sites for schools near cleaned-up toxic waste sites or other sources of radiation or chemicals, they are relying on an outdated measure of the health risks posed to children by such environmental hazards, according to a report released today by a coalition of scientists, physicians, cancer prevention specialists, children’s health organizations, and women’s groups. In an open letter to President Bush, the Institute for Energy and Environmental Research urged a shift of federal regulations from measuring environmental effects on adult males—the current "Reference Man" —to more comprehensive exposure standards that include children. Currently, "Reference Man" is officially defined internationally as being between 20 and 30 years of age, weighing 70 kg (154 pounds), 170 centimeters (5 feet 7 inches) tall, living in a climate with an average temperature of between 20 and 30 degrees centigrade, and "a Caucasian and Western European or North American in habit and custom." That standard is widely used to decide, for example, how much residual radiation will be allowed in radioactively contaminated soil, where a new power plant will be built, or how much medical radiation an individual can safely receive. But the Reference Man criterion leaves out an awful lot of people, especially children and women, the Institute points out, which is important because children and women, especially those who are pregnant or nursing, are especially vulnerable to environmental toxins. The Institute reminds the President that he signed an executive order on protecting children from environmental hazards three years ago, which acknowledges that children are "disproportionately vulnerable to environmental hazards." Information about the Institute’s report, "Science for the Vulnerable: Setting Radiation and Multiple Exposure Environmental Standards to Protect Those Most at Risk," is available at http://www.ieer.org. October 20, 2006Agencies Caution about Internet Ads for Diabetes Cures Two federal agencies—the Food and Drug Administration (FDA) and the Federal Trade Commission (FTC)—joined October 19 to warn against deceptive Internet advertisements that claim to treat or cure diabetes. The caution came after a websurf conducted by law enforcement authorities in the United States, Canada, and Mexico uncovered numerous practices that "raise false hopes and bilk consumers of precious health care dollars," according to the FDA. In addition to alerting the public via a consumer education program, the FDA has sent warning letters to 24 firms that market dietary supplements claiming to cure, prevent, or mitigate diabetes; and the FTC has sent warning letters to 84 domestic and 7 Canadian websites that target U.S. consumers. The FDA notes that it maintains special websites in English and Spanish that "amplify the agency’s counsel to consumers to check with their doctor, nurse, or pharmacist before trying any new health care product." Of special interest to diabetes patients, the FDA says, are websites http://www.fda.gov/diabetes and http://www.fda.gov/diabetes/pills.htm. October 27, 2006SAMHA Cites Non-Medical Use of Prescription Drugs by Teens Misuse of prescription drugs, including pain relievers, tranquilizers, stimulants, and sedatives, is second only to marijuana as the nation’s most prevalent drug problem, and many of the people who misuse those drugs are 12 to 17 years old, according to a report released today by the Substance Abuse and Mental Health Services Administration (SAMHSA). The report specifically mentions some medications that are commonly misused, including OxyContin, Percocet, and Vicodin. "Misuse" is defined as "use of these medications without a prescription or simply for the experience or feeling the drug caused." Young people commonly get their drugs from friends or relatives, or from the family medicine cabinet, the report indicates, and SAMHSA urges parents and other caregivers to store their prescription drugs carefully and to dispose of any unused drugs "before they can fall into the wrong hands." Today’s report, "Misuse of Prescription Drugs: Data from the 2002, 2003 and 2004 National Survey on Drug Use and Health," is online at http://oas.samhsa.gov.
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