News (Updated May 14, 2006)
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By LAURAN NEERGAARD, AP Medical WriterThu May 11, 8:37 PM ET
Who should get the first flu vaccine during a worldwide outbreak — the 60-year-old grandmother with a weak heart and lungs or the healthy 4-year-old with decades ahead of her?
Government guidelines put the ill grandmother at the head of that line, for now.
Younger, healthier people should be moved ahead, argue bioethicists at the National Institutes of Health, raising new issues to consider as federal officials review the nation's pandemic guidelines.
"Death seems more tragic when a child or young adult dies than an elderly person — not because the lives of older people are less valuable, but because the younger person has not had the opportunity to live and develop through all stages of life," Drs. Ezekiel Emanuel and Alan Wertheimer wrote for Friday's edition of the journal Science.
It's a different way of weighing the agonizing decision of how to ration scarce vaccine if a super-strain of influenza sparks a worldwide epidemic. If that flu arises, it will take manufacturers months to brew inoculations for everyone.
First doses will go to workers in vaccine factories and to people caring for the ill, a Bush administration decision widely shared by health specialists, including the two bioethicists.
The question is who to inoculate next.
Federal health advisers have recommended that people up to age 64 who have at least two high-risk health conditions — such as asthma, heart disease, emphysema — be first in that line.
Next would come pregnant women and people who come in contact with people who have poor immune systems, such as HIV or chemotherapy patients. They're followed by key government leaders and healthy people over age 65.
At the end of the list, after funeral directors, come healthy people ages 2 to 64.
The list is part of the government's evolving pandemic plan. It is under discussion and not final.
It rests on a long-used public health principle, that the people most vulnerable to dying from a disease should be vaccinated first. In an average winter, flu mostly kills the elderly. No one knows if that will hold true during a pandemic; in 1918, history's worst pandemic, young adults were the chief victims.
To the average person, protect-the-young is an equally powerful principle, argues Emanuel, who also treats cancer and notes that the 65-year-old who succumbs is often mourned with the "but he had a good life" comfort that's missing when a child dies.
But youngest-first is too simple, Emanuel concluded. So he also considered how much has been invested in a young person's future, plus a "public order" principle that gives priorities to providers of necessities like food and fuel.
Combining those ideas, he wants healthy 13-to-40-year-olds to get scarce flu inoculations right after the vaccine makers and health workers — especially those who are police officers, utility workers or in other professions important to societal order. They would be followed by younger children and the middle-aged, with the sick elderly last in line.
"We need principles people share (such as) this protective instinct for young people to allow them to lead a full life," said Emanuel, whose paper doesn't reflect NIH policy but his own opinion.
Other alternatives already are being debated, such as whether preschoolers and schoolchildren should be among the first vaccinated during a pandemic because they are the main spreaders of influenza.
And the government advisers who recommended the current guidelines first strongly considered putting police officers and truck drivers at the head of the line. Then, "not only can the truck driver keep delivering goods, he or she will be protected and cannot give it to others," said Dr. William Schaffner, a Vanderbilt University flu specialist who was part of those debates.
"There is no single right answer," said Schaffner, who praised the new article's call for wide public discussion about the hard choices that would have to be made. "These are prioritizations that should be transparent."
The government wants public input, said Dr. Bruce Gellin, who heads the federal vaccine policy office.
"There should be vigorous public discussion about this," Gellin said. "It's important that people know what's in the plan and begin to think what it may mean for them."
By MIKE STOBBE, Associated Press WriterTue May 9, 8:05 PM ET
Testing for the AIDS virus could become part of routine physical exams for adults and teens if doctors follow new U.S. guidelines expected to be issued by this summer. Federal health officials say they'd like HIV testing to be as common as a cholesterol check.
The guidelines for voluntary testing would apply to every American ages 13 to 64, according to the proposed plan by the U.S. Centers for Disease control and Prevention.
One-quarter of the 1 million Americans with the AIDS virus don't know they are infected, and that group is most responsible for HIV's spread, CDC officials said.
"We need to expand access to HIV testing dramatically by making it a routine part of medical care," said the agency's Dr. Kevin Fenton.
CDC officials first disclosed the plans at a scientific conference in February. Last week, they said the guidelines should be released in June or July.
The recommendations aren't legally binding, but they influence what doctors do and what health insurance programs cover.
Currently, the CDC recommends routine testing for those at high-risk for catching the virus, such as IV drug users and gay men, and for hospitals and certain other institutions serving areas where HIV is common.
Under the new guidelines, patients would be tested for HIV as part of a standard battery of tests they receive when they go for urgent or emergency care, or even during a routine physical.
Patients wouldn't get tested every year: Repeated, annual testing would only be recommended only for those at high-risk.
There would be no consent form specifically for the HIV test; it would be covered in a clinic or hospital's standard care consent form. Patients would be allowed to decline the testing.
Standardizing HIV testing should reduce the stigma as well as transmission, CDC officials said. Nearly half of new HIV infections are discovered when doctors are trying to diagnose an illness in a patient who has come for care, they noted.
The American Medical Association supports the proposed recommendations, said Dr. Nancy Nielsen, a Buffalo, N.Y.-based physician who is speaker of the AMA's House of Delegates.
Some doctor's offices will face challenges implementing the recommendations, she added. For example, they should not give a positive HIV test result over the phone and would have to provide or arrange for counseling.
But the benefits of reducing the spread of HIV far outweigh the logistical challenges, said Nielsen, an infectious disease specialist.
"I'm so happy the CDC is recommending this," she said. "HIV is an infectious disease and it should be treated like any other infectious disease. The fact that it has been treated so differently, I think, in some ways has contributed to the stigma."
Some patients' advocates have voiced concern that the recommendations do not include pre-test counseling and sufficient informed consent.
At many HIV testing sites, patients sit through a counseling session to explain the procedure before any blood is drawn. Many centers also require a patient to give "informed consent," indicating they understand the risks and benefits of the test.
The new recommendations, as currently drafted, do not require pre-test counseling. They call for post-test counseling to be offered only to patients who test positive.
CDC officials say they understand advocates' concerns, and are optimistic physicians will follow the recommendations carefully.
"Doctors should be explicit that 'You're going to be tested,'" said Dr. Tim Mastro, acting director of the CDC's division of HIV/AIDS prevention.
Tuesday May 9, 5:06 AM
Lesbians' brains react differently to sex hormones than those of heterosexual women, new research indicates. That's in line with an earlier study that had indicated gay men's brain responses were different from straight men _ though the difference for men was more pronounced than has now been found in women.
Lesbians' brains reacted somewhat, though not completely, like those of heterosexual men, a team of Swedish researchers said in Tuesday's edition of Proceedings of the National Academy of Sciences.
A year ago, the same group reported findings for gay men that showed their brain response to hormones was similar to that of heterosexual women.
In both cases the findings add weight to the idea that homosexuality has a physical basis and is not learned behavior.
"It shows sexual orientation may very well have a different basis between men and women ... this is not just a mirror image situation," said Sandra Witelson, an expert on brain anatomy and sexual orientation at the Michael G. DeGroote School of Medicine at McMaster University in Hamilton, Ontario.
"The important thing is to be open to the likely situation that there are biological factors that contribute to sexual orientation," added Witelson, who was not part of the research team.
The research team led by Ivanka Savic at the Stockholm Brain Institute had volunteers sniff chemicals derived from male and female sex hormones. These chemicals are thought to be pheromones _ molecules known to trigger responses such as defense and sex in many animals.
Whether humans respond to pheromones has been debated, although in 2000 American researchers reported finding a gene that they believe directs a human pheromone receptor in the nose.
The same team reported last year on a comparison of the response of male homosexuals to heterosexual men and women. They found that the brains of gay men reacted more like those of women than of straight men.
The new study shows a similar, but weaker, relationship between the response of lesbians and straight men.
Heterosexual women found the male and female pheromones about equally pleasant, while straight men and lesbians liked the female pheromone more than the male one. Men and lesbians also found the male hormone more irritating than the female one, while straight women were more likely to be irritated by the female hormone than the male one.
All three groups rated the male hormone more familiar than the female one. Straight women found both hormones about equal in intensity, while lesbians and straight men found the male hormone more intense than the female one.
The brains of all three groups were scanned when sniffing male and female hormones and a set of four ordinary odors. Ordinary odors were processed in the brain circuits associated with smell in all the volunteers.
In heterosexual males the male hormone was processed in the scent area but the female hormone was processed in the hypothalamus, which is related to sexual stimulation. In straight women the sexual area of the brain responded to the male hormone while the female hormone was perceived by the scent area.
In lesbians, both male and female hormones were processed the same, in the basic odor processing circuits, Savic and her team reported.
Each of the three groups of subjects included 12 healthy, unmedicated, right-handed and HIV-negative individuals.
The research was funded by the Swedish Medical Research Council, Karolinska Institute and the Wallenberg Foundation.
(Proceedings of the National Academy of Sciences)
Fri May 12, 2006 11:46 PM ET
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Chancroid, a highly contagious STD, is very common in Africa and becoming more common in the United States. Chancroid can be effectively treated with antibiotics. Left untreated, chancroid may facilitate the transmission of HIV, the virus that causes AIDS.
Elkins, at the University of North Carolina in Chapel Hill, and his associates purified a key part of Haemophilus ducreyi, the bug that causes chancroid, and used it to vaccinate pigs on days 1, 21, and 42. Three weeks later, they inoculated the animals' skin with Haemophilus ducreyi. They report their results in the journal Infection and Immunity.
Even though characteristic chancroid lesions developed on the vaccinated pigs, the lesions 7 days later were smaller and less inflamed compared with lesions in pigs that were vaccinated with a placebo.
At the same time, lesions of the vaccinated pigs were sterile, whereas all 17 biopsies from sham-vaccinated pigs yielded viable Haemophilus ducreyi. Moreover, the blood of vaccinated pigs had high levels of antibodies against the chancroid bug.
Prevention of chancroid lesions may reduce transmission of HIV, because "high concentrations" of HIV-susceptible cells are present in chancroid ulcers, Elkins explained.
SOURCE: Infection and Immunity, April 2006.
Wed May 10, 2006 07:56 PM ET
By Megan Rauscher
NEW YORK (Reuters Health) - In the United States, bacterial vaginosis disproportionately affects African American women, according to research reported Wednesday in Jacksonville, Florida at the 2006 National STD Prevention Conference sponsored by the Centers for Disease Control and Prevention. Trichomoniasis is also more prevalent among African-American women, according to related research reported at the meeting.
Bacterial vaginitis, the most common vaginal infection in women of childbearing age, occurs when the normal balance of bacteria in the vagina is disrupted and replaced by an overgrowth of other bacteria. The infection is sometimes accompanied by discharge, odor, pain, itching or burning.
Trichomoniasis is caused by the single-celled protozoan parasite, Trichomonas vaginalis, and is transmitted through sexual contact. Some but not all women develop a yellow-green vaginal discharge with a strong odor. It may also cause discomfort during intercourse and urination, as well as irritation and itching of the female genital area
The findings of a nationally representative sample of about 2000 women between the ages of 14 and 49 years old, indicate that more than one quarter of all U.S. women (27.4 percent) compared with half of non-Hispanic black women (50.3 percent) have bacterial vaginosis.
"Black women were about twice as likely as either white women, who had a prevalence of 22 percent, or Mexican-American women, who had a prevalence of 28 percent, to have bacterial vaginosis," the CDC's Dr. Emilia Koumans reported.
Factors associated with bacterial vaginosis were douching, having an annual family income less than $20,000, having been pregnant, black race, and for white women, increasing numbers of sex partners.
Using the same study data, Koumans and colleagues also found that the overall prevalence of trichomoniasis among U.S. women is 3 percent. However, among non-Hispanic black women, the prevalence is 13.5 percent.
"Black women were more than nine times more likely to be infected than either white women, who had a prevalence of 1.2 percent, or Mexican-American women, who had a prevalence of 1.5 percent," Koumans reported.
As with many other STDs, the higher prevalence of trichomoniasis among black women likely reflects underlying socioeconomic factors, such as poverty and limited access to healthcare, and having a social network with a high prevalence of STDs.
"Trichomoniasis is easily treated, as is bacterial vaginosis, with a single dose of medication taken orally or with a course of intravaginal antibiotics," Koumans said.
Summing up, Dr. John M. Douglas Jr., of the CDC noted that bacterial vaginosis and trichomoniasis are "extremely common but under recognized health threats for sexually active women and their babies."
"Like many serious STDs in women, they often go undiagnosed and when left untreated they carry risks for potentially serious health problems including premature and low birth weight babies and an increased risk of acquiring HIV. Bacterial vaginosis is also associated with pelvic inflammatory disease, which can lead to infertility."
Wed May 10, 2006 01:45 PM ET
By Maggie Fox
WASHINGTON (Reuters) - Young women risk being infected with Chlamydia more than once, researchers reported on Tuesday in a series of studies showing just how vulnerable younger women are to the disease.
But other studies presented at the Centers for Disease Control and Prevention STD prevention conference showed that screening people can reduce the rate of infection across entire communities.
The findings also show that younger women are more susceptible to and do not understand the risks of not only Chlamydia, but other STDs as well, the researchers said at the conference in Jacksonville, Florida.
Chlamydia is the most common STD among women and, in 70 percent of cases, causes no symptoms. The bacterial infection can lead to pelvic inflammatory disease, ectopic pregnancy and infertility. It can also make a woman more likely to be infected with or to pass on the AIDS virus.
New York City Department of Health researchers Ellen Klingler and colleagues tested nearly 40,000 women in two studies, one in 2000 and another from 2003 to 2004. One in eight women diagnosed with Chlamydia citywide had a repeat infection within 1 year.
The women younger than 19 were much more likely to have been infected repeatedly than women older than 25, they found. A study of 400,000 women making routine doctor visits in California found similar rates, with 1 in 10 infected with Chlamydia becoming reinfected within 6 months.
"These findings tell us that many young women who are treated for Chlamydia are likely being reinfected by male partners who are not being diagnosed and treated," said Dr. Ronald Valdiserri, director of the National Center for HIV, Sexually Transmitted Diseases and Tuberculosis Prevention.
WORKING HARDER TO EDUCATE
Valdiserri said doctors and clinics need to work harder to get women to notify their sexual partners, routinely re-screen women, and perhaps try innovative approaches such as giving the women antibiotics to take to their partners.
An Emory University study done of 800 college and university students in Georgia, Mississippi and Alabama showed that 9.7 percent of all the young women had Chlamydia but 13 percent of the freshmen, or first-year, women were infected.
Dr. Pennan Barry of the San Francisco Department of Public Health and colleagues at the San Francisco County Jail found that screening and treating inmates protected not just the men and women in jail, but their communities.
From 1997 to 2004 more than 31,000 men and 11,700 women inmates were screened and treated for Chlamydia and other STDs. Then the researchers looked at the neighborhoods where the inmates came from.
There, rates of Chlamydia among young women fell by half between 1997 and 2004, from 15 percent to 8 percent. That compared to a 6 percent decrease, from 3.3 percent to 3.1 percent, in neighborhoods where jail inmates did not live.
Other researchers found many women are engaging in risky behaviors.
Dr. Charlotte Gaydos and colleagues at Johns Hopkins University found that among women using an online STD self-testing program, at http:// www.iwantthekit.org., more than 15 percent said they had four or more sex partners in the past year.
Just 16 percent of the women with Chlamydia and 12 percent of the uninfected women reported always using condoms.
Another study at Johns Hopkins University found the number of 15- to 25-year-old females treated at Baltimore STD clinics over the past decade who reported having oral sex more than doubled, from 14 percent to 38 percent.
The number of young women reporting they had anal sex nearly doubled, from 3 percent to 5.5 percent.
The deal will save annually 15.2 million dollars to include tenofovir in the cocktail of anti-retroviral drugs given HIV/AIDS sufferers.
"We are in negotiations with all of the producers of anti-retrovirals" for price cuts, Brazilian Health Minister Agenor Alvares said.
The deal not only guarantees a supply of the drug for Brazil, but also "brings an considerable savings that must be used in the acquisition of other drugs," said Alvares, who signed the deal with Joseph Steele, vice president of the US pharmaceuticals company.
Brazil began a program in 1996 to assure free treatment for all those infected with HIV/AIDS, resulting in a 40 percent reduction in deaths.
According to recent data, 170,000 Brazilians benefit from the program and distribution of 17 anti-AIDS medications, which cost the government 411 million dollars in 2005.
Eight of the 17 are manufactured in Brazil but the others are imported.
Since 2002 Brazil has pressed AIDS/HIV drug producers to cut prices. Last year they persuaded Abbott Laboratories to reduce the price on its drug Kaletra.