IDSA News - July 2009
Vol. 19 No. 7
(Print All Articles)

From the President: IDSA’s Role in Health Care Reform

As the health care reform debate continues, IDSA is actively monitoring developments and legislative proposals on Capitol Hill and working to ensure that ID and HIV/AIDS priorities are addressed. 

As the health care reform debate continues, IDSA is actively monitoring developments and legislative proposals on Capitol Hill and working to ensure that ID and HIV/AIDS priorities are addressed. We support the two primary goals of reform: making affordable health coverage available to all Americans and slowing the unsustainable rise in health care costs.

Our focus has been on issues that affect the fields of infectious diseases, our members, and their patients, and we have worked to make the most effective use of IDSA’s and the HIV Medicine Association (HIVMA)’s most valuable resource—the knowledge and expertise of our members.

Specifically, through letters to members of Congress, congressional testimony, media outreach, and partnerships with related organizations, we have:

• Focused on the importance of evidence-based prevention and wellness. IDSA supports increasing national investments in prevention and public health. We have also called for all insurance plans, public and private, to cover a wide variety of preventive services, including routine HIV testing and access to all federally recommended immunizations for adults, adolescents, and children.
• Tried to ensure that changes in Medicare and Medicaid encourage clinicians to provide high-quality and efficient care instead of simply more care, such as through financial support for the medical home model used by many HIV programs. We have also tried to make sure that these new approaches do not unfairly penalize ID specialists, whether in the public or private sector (see related article).
• Supported a permanent fix to the Centers for Medicare and Medicaid Services (CMS)’s reimbursement system and the Sustainable Growth Rate. Physicians will continue to face steep reimbursement cuts until a permanent fix is made.
• Endorsed HIVMA’s support for a public plan option for health insurance coverage. A public plan option would ensure affordable access to comprehensive care for HIV patients—nearly 30 percent of whom have no insurance today. HIVMA is particularly concerned that private insurers will discourage HIV patients from enrolling in private plans by excluding HIV clinicians and programs.
• Highlighted the need to ensure an adequate and well-trained HIV medical workforce. Efforts directed at the primary care workforce, including loan forgiveness and financial support for training, also should be offered to HIV clinicians to help address a serious crisis in HIV care capacity.

In addition to these issues, we have called on lawmakers to incorporate other ID priorities into health reform. This includes improving access to antimicrobial home infusion therapy by eliminating gaps in Medicare coverage, moving coverage of all vaccines under Medicare from Part D to Part B, strengthening the federal approach to dealing with drug-resistant pathogens, and requiring national reporting of healthcare-associated infections.

You can download a one-page summary of IDSA’s priorities. This page on IDSA’s website includes more details about our advocacy on health care reform. You can also check IDSA’s homepage, under “New at IDSA,” for more timely updates.

It’s not yet clear how the current debate in Washington will end. But as the process unfolds, we will continue to track developments and offer policymakers feedback, always mindful of what matters most to the ID specialty, IDSA members, and their patients.

ACIP Recommends Groups for H1N1 Vaccination

During a special meeting earlier this week, the federal Advisory Committee on Immunization Practices (ACIP) made recommendations for which groups should receive the novel influenza A:H1N1 vaccine.

The federal Advisory Committee on Immunization Practices (ACIP) made recommendations this month for the use of the novel influenza A:H1N1 vaccine. During a special meeting, ACIP recommended five target groups for vaccination:

• pregnant women
• people who live with or care for children under 6 months of age
• health care workers and emergency services personnel
• those between 6 months and 24 years of age
• people between the ages of 25 and 64 who are at higher risk for H1N1 infection because of chronic health disorders or compromised immune systems

These groups represent about 159 million people in the United States. Although no shortage of the H1N1 vaccine is expected, ACIP also identified five groups that should receive the vaccine before others if supply is limited:

• pregnant women
• people who live with or care for children under 6 months of age
• health care workers and emergency services personnel with direct patient contact
• children 6 months through 4 years of age
• children 5 through 18 years of age who have chronic medical conditions

Once demand for the vaccine among these priority groups has been met, providers and programs should begin vaccinating everyone between the ages of 25 and 64, ACIP recommended. As the vaccine demand among younger age groups is being met, H1N1 vaccination should be offered to people over the age of 65. ACIP also stressed that people in this age group receive the seasonal influenza vaccine as soon as it available. Current studies indicate the risk for H1N1 infection among those older than 65 is less than the risk for younger age groups.

The new H1N1 vaccine is not intended to replace the seasonal influenza vaccine but is intended to be used alongside the seasonal vaccine. Both vaccines may be administered on the same day, according to the Centers for Disease Control and Prevention (CDC). For more information, see CDC’s webpage and press release on the vaccination recommendations.

IDSA Urges Changes to Address Regulatory Burdens Slowing Needed Research

Regulatory burdens are slowing important clinical research — and creating obstacles to improving patient care — according to an IDSA policy statement recently published in Clinical Infectious Diseases. 

More than other any other medical field, ID relies on research to explore the intersection between humans and a microbial world that is constantly changing and creating new infections every year. But existing regulatory burdens are slowing this important work—and creating obstacles to improving patient care—according to an IDSA policy statement recently published in Clinical Infectious Diseases.

“The future of our field, and all medical fields, is closely tied to research,” said William Burman, MD, medical director of the Infectious Diseases Clinic at Denver Health and lead author of the policy statement, which was developed by IDSA’s Research Committee. “There are people who decide to not go into research because of the frustration in dealing with these regulations. Our concern is that patients will suffer because less is known about their infections.”

The statement focuses on five key problem areas that ultimately slow research and increase costs:

• the impact of the Health Insurance Portability and Accountability Act (HIPAA)
• local review of multicenter studies
• redundancy in the reporting process for adverse events
• barriers related to pediatric research
• the role of Institutional Review Boards (IRBs) in quality improvement projects

To address these concerns, IDSA offers several recommendations to ease these burdens while also protecting research participants. These steps include: clarifying rules that govern the oversight of pediatric research, quality improvement efforts, and adverse event reporting; encouraging the National Institutes of Health (NIH) to establish central IRBs at all its major institutes and centers to review multicenter studies, in addition to providing incentives for local institutions and researchers to use central review; and removing research from the purview of HIPAA regulation, which was not originally intended for this purpose.

Earlier this month, IDSA sent a letter to Anthony S. Fauci, MD, director, National Institute of Allergy and Infectious Diseases (NIAID), highlighting these concerns and urging the institute to adopt a system of central review panels similar to those adopted by the National Cancer Institute to review multicenter studies. In his response, Dr. Fauci agreed that a centralized IRB system is important in facilitating multicenter studies and noted that he looked forward to having further discussions with IDSA.

To raise awareness of the regulatory burdens facing clinical research and to advocate for change, IDSA asked members who conduct research to share their own experiences in an online survey. The Society plans to work with other organizations, including other medical groups, to push for changes in these areas.

Journal Club

July 2009

This month: the H1N1 outbreak and recent triple-reassortant swine influenza A (H1) strains, determining the pandemic potential of H1N1, universal antenatal group B streptococcus screening, and the Diarylquinoline TMC207 and MDR-TB treatment.

In this feature, a panel of IDSA members identifies and critiques important new infectious diseases studies in the current literature that have a significant impact on the practice of infectious diseases medicine.

• An Evolving Story: The Novel H1N1 Outbreak and Recent Triple-Reassortant Swine Influenza A (H1) Strains
• Determining the Pandemic Potential of Novel H1N1 Influenza
• Universal Antenatal Group B Streptococcus Screening: Successful, But There Is Room for Improvement
• The Diarylquinoline TMC207 and MDR-TB Treatment

In March, two children in Southern California developed routine respiratory tract infections. As participants in surveillance studies, the children had viral cultures taken and, by April, were found to have been infected with swine-origin influenza A (H1N1) virus—representing the first two identified cases of the current pandemic in the United States. In the June 18 issue of The New England Journal of Medicine, two articles provide a snapshot of the U.S. outbreak through early May and describe the clinical aspects of 11 domestic triple-reassortant swine influenza A (H1) viruses, which were reported to the Centers for Disease Control and Prevention (CDC) between December 2005 and February 2009, just before the pandemic began.

The triple-reassortant viruses identified were of two types: H1N1 (10 patients) and H1N2 (one patient). In these viruses, the polymerase PB1 gene was of human influenza origin, the polymerase PB2 and polymerase PA genes were of avian influenza origin, and the remaining five genes were of classic swine influenza origin. The median age of the 11 patients was 10 years (16 months to 48 years). Exposure to pigs was reported in nine patients. Ten patients developed symptoms: fever (90 percent), cough (100 percent), headache (60 percent), and diarrhea (30 percent). Four patients were hospitalized, including two who required mechanical ventilation. However, all recovered from their illness, although only four patients received the neuraminidase inhibitor, oseltamivir.

The second article describes the scope of the novel influenza A:H1N1 outbreak in the United States from April 15 through May 5, when 642 confirmed domestic cases had been reported. (For more current data about probable and confirmed cases, visit CDC’s H1N1 web page.) Although 60 percent of the patients were under the age of 19, ages ranged from 3 months to 81 years. Only 18 percent were noted to have recently travelled to Mexico. Symptoms included: fever (94 percent), cough (92 percent), sore throat (66 percent), diarrhea (25 percent), and vomiting (25 percent). Although the database was incomplete, 9 percent of those with information available were hospitalized, at least half having increased risk for severe seasonal influenza. Two deaths were identified in the cohort. Genetically, this latest novel H1N1 strain is related to, but distinct from, the triple-reassortant viruses described above. While it possesses the same human and avian genes seen before, the two genes encoding neuraminidase (NA) and M protein (M) are related to swine influenza A strains from Eurasia. Thus, this H1N1 strain indeed represents a triple-reassortant virus not previously described anywhere. The story of this virus is evolving rapidly, but these articles provide insight on what to expect in the future.

(Shinde et al. N Engl J Med 2009; 360:2616-2625 and Novel Swine-Origin Influenza A (H1N1) Virus Investigation Team. N Engl J Med 2009; 360:2605-2615.)

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The pandemic potential of the novel H1N1 influenza strain that emerged in Mexico in April was assessed by investigators affiliated with the World Health Organization (WHO) in an article published in the June 19 issue of Science.

Investigators used the incidence of H1N1 infection among travelers returning from Mexico to estimate that approximately 23,000 patients had been infected in Mexico by late April. Based on 117 deaths in Mexico suspected to be related to H1N1 as of May 4, the case fatality ratio (CFR) was initially estimated at 0.4 percent and later adjusted to 0.091 percent by April 23, when only 21 H1N1-related deaths had been confirmed. No deaths were reported among 616 residents with presumed H1N1 infection in the small, isolated community of La Gloria in Veracruz, where the earliest cases in the outbreak were described, leading to an estimate of the upper limit of the CFR at 0.6 percent, lower than that associated with the 1918 influenza pandemic (2-3 percent).

The first case in La Gloria was reported Feb. 15; 616 suspected cases among 1,575 residents were reported by April 14. Genetic analysis of viral samples determined the time of the most recent common viral ancestor to be Jan. 12, with a doubling time of the epidemic estimated at 10 days. This data yielded reproductive number estimates (R_o: number of cases one case generates, on average, over the course of its infectious period) in the range of 1.2-1.6, higher than that associated with seasonal flu and approaching R_o estimates associated with the 1918 pandemic (1.3-2.1). Fourteen to 73 generations of human-to-human transmission were estimated to have occurred in Mexico by late April, indicating sustained human-to-human transmission.

These findings provided the rationale for WHO’s decision to raise the global pandemic influenza alert to Phase 5 and later to Phase 6, indicating a global influenza pandemic. Ongoing study of clinical severity associated with—and transmissibility of—this novel H1N1 strain will be vital in informing public health efforts to mitigate its spread.

(Fraser et al. Science 2009;324:1557-61.)

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Implementation of universal antenatal screening for group B streptococcus (GBS) has led to a decline in the overall incidence of early-onset GBS disease in infants, according to a recent study in the June 18 issue of The New England Journal of Medicine.

Early-onset GBS disease, which occurs during the first seven days of life, is a major cause of infant mortality. In 2002, universal GBS screening by culture was adopted for pregnant women in the United States. This retrospective cohort study examined more than 7,000 live births in 10 states in the United States from 2003 to 2004 and compared them to births that occurred from 1998 to 1999, prior to implementation of universal screening guidelines. The authors found that screening increased dramatically from 48.1 percent to 85 percent after adoption of the guidelines. However, only 49.4 percent of women screened had documented testing during the appropriate time period, after 35 weeks gestation. Factors associated with missed screening included absence of prenatal care, drug use, preterm delivery, as well as black race and Hispanic ethnicity. Mothers who delivered preterm were also less likely to receive chemoprophylaxis for GBS when indicated.

Despite the high rates of testing in mothers of term infants, 74.4 percent of cases of early-onset GBS disease occurred in term infants. The majority (61.4 percent) of these cases occurred in infants of mothers who had received appropriate screening but tested negative for GBS. These false negative cases, which may be explained by transient colonization, were greater in number than expected.

Adoption of universal screening for GBS has led to a significant decrease in the incidence of early-onset GBS disease. But increased screening for preterm deliveries, as well as improved timing and documentation of testing, would likely lead to a further decrease in disease incidence.

(Van Dyke et al. N Engl J Med 2009;360:2626-2636.)

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As a cause of death from infection worldwide, tuberculosis ranks second only to HIV/AIDS. One-third of the world’s population is thought to be living with latent TB infection, a situation made even worse by emerging resistance to TB drugs. Resistant to both rifampin and isoniazid, multi-drug-resistant TB (MDR-TB) accounts for about 5 percent of new cases and 6 percent of TB deaths globally. Existing therapy for MDR-TB consists of prolonged treatment with multiple second-line agents, often with limited efficacy.

A South African study of the mycobacterial ATP synthase agent, TMC207, published in the June 4 issue of The New England Journal of Medicine, offers some hope. In this Phase II, randomized, placebo-controlled trial, the authors report on the safety, adverse events, and antibacterial activity of the drug. The study is admittedly small (47 patients), but the efficacy of standard therapy—in this case, kanamycin, ofloxacin, ethionamide, pyrazinamide, and cycloserine or terizodone—is so low that smaller-scale trials might be sufficient to show a relevant effect of the new agent. In this eight-week trial, participants with MDR-TB were randomly assigned to treatment with: (1) TMC207 400 mg daily for two weeks, followed by 200 mg TID for the remaining five weeks in conjunction with standard five-drug therapy; or (2) placebo in conjunction with standard five-drug therapy for eight weeks. The primary endpoint was conversion of sputum cultures from positive to negative.

Adding TMC207 to the standard regimen resulted in quicker conversion to a negative sputum culture compared to placebo (hazard ration, 11.8; 95 percent CI, 2.3 to 61.3; P=0.003). The actual rates were 48 percent in the TMC207 group compared with 9 percent in the placebo group. Rates of smear negativity were also greater at week four (77 percent vs. 57 percent) and at week eight (84 percent vs. 68 percent) for the TMC207 group. Nausea was significantly more common in the TMC207 group (26 percent vs. 4 percent, P=0.04) but did not lead to attrition from the study in either arm, suggesting it was overall mild and manageable.

Encouraging as these results are, a second stage of this Phase II study remains to be completed. This second stage will be a proof-of-efficacy phase and should further elucidate the role of TMC207 for the treatment of MDR-TB, and as importantly, the potential of ATP synthase as an important target for further drug development.

(Diacon et al. N Engl J Med 2009;360:2397-2405.)

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Review Panel Hears Range of Views on Lyme Disease

A special IDSA review panel held a hearing this month during which a wide range of perspectives on Lyme disease were aired, including views from prominent researchers, practicing physicians, and patients. IDSA established the review panel to examine whether the Society’s 2006 guidelines should be revised or updated.

A central question explored at the hearing was whether Lyme disease can persist as a chronic infection that can be successfully treated with an extended course of antibiotics.

The panel heard from some of the authors of IDSA’s guidelines, who concluded there is no convincing biologic evidence for symptomatic, chronic Borrelia burgdorferi infection after completion of the recommended treatment for Lyme disease, which, according to IDSA’s guidelines, is 10-28 days, depending on the stage of illness. Longer-term antibiotics may be dangerous and can lead to complications, according to IDSA.

But the panel also heard from several representatives of the International Lyme and Associated Diseases Society (ILADS), who argued for more extensive treatment for what ILADS identifies as chronic Lyme disease.

“In one sense, this panel’s job is standard practice, because all guidelines must be reviewed periodically to make sure they keep pace with science,” said Carol J. Baker, MD, FIDSA, chair of the review panel. “But this panel’s job is unique, because our focus goes beyond the usual approach to guidelines review by soliciting input from the general public, as well as the scientists who study Lyme disease and the physicians who treat it.”

Over the next several months, the panel will continue to review the medical and scientific literature as well as material submitted by the 18 individuals who testified at the July 30 hearing and about 150 other comments submitted by the public. The panel’s final report will recommend one of the following options: no change in the 2006 guidelines, sectional revision, or a complete rewrite. If the panel recommends a change or rewrite, then IDSA will convene a separate panel to carry out that task. 

IDSA is conducting the review as part of its voluntary agreement with the Attorney General of Connecticut, who had questioned the process used by IDSA’s 2006 guidelines panel but made no claims about the validity of IDSA’s medical recommendations. Members of the review panel were jointly selected through an open application process to ensure that the panel reflects a balanced variety of perspectives and experience.

“We hope to move forward as quickly as possible, while allowing adequate time to review all the medical evidence and other information submitted by the public,” Dr. Baker said. “We are all committed to seeing that people with Lyme disease get the best possible care and that the recommendations in IDSA’s guidelines are safe, effective, and based on sound medical evidence.”

The panel is expected to issue its final recommendation by the end of the year. Click here for an online archive of the hearing.

EIN: Treatment Options for H1N1 Pneumonia and Antiviral Use in Infants

The Emerging Infections Network (EIN) is a forum for infectious diseases consultants and public health officials to report information on clinical phenomena and epidemiological issues with public health significance. Any diagnostic or therapeutic recommendations and all opinions presented are those of the individual contributor. They do not necessarily represent the views of EIN, IDSA (EIN's sponsor), or the Centers for Disease Control and Prevention, which funds the EIN. The reader assumes all risks in using this information.

As the novel influenza A:H1N1 outbreak continues, EIN members have been discussing related treatment questions. One EIN member from Massachusetts asked about the value of corticosteroid therapy for patients with influenza viral pneumonia who are not responding to oseltamivir.

One member from North Dakota reported anecdotal improvement with methylprednisolone; however, other respondents urged caution. A member in Utah cited guidance from a WHO expert consultants group that reviewed data on steroids and avian influenza A:H5N1 and concluded steroids were associated with increased mortality. While the respondent noted the significant differences between the two influenza strains, he added that both are characterized by hemorrhagic pneumonitis and acute respiratory distress syndrome in immunologically naïve subjects.

A Florida EIN member referred to WHO’s initial guidance document regarding clinical management of the latest H1N1 strain. The member’s review of the literature also found:

• no benefit from steroids for severe acute respiratory syndrome (SARS), avian influenza, hantavirus pulmonary syndrome, respiratory syncytial virus (RSV), or pneumocystis pneumonia (PCP)
• some benefit in cases of parainfluenza and in croup from parainfluenza in children
• “lots of literature on steroids increasing the risk of secondary infections such as mold and CMV”

In addition, the member cited a 2008 article in the International Journal of Hematology that described a bone marrow transplant recipient with severe parainfluenza 3 pneumonia who was successfully treated with oral ribavirin and methylprednisolone.

“I have seen many cancer and [bone marrow transplant] patients improve dramatically with severe viral pneumonia when corticosteroids are added with antivirals and aggressive follow-up and, at times, prophylaxis for secondary infections and rapid steroid taper over 1-2 weeks,” the member said. “However, many reputable colleagues who are very anti-steroid will disagree with me.” The truth, he added, is in the middle: “Some patients benefit, and many have no benefit, and in some it is detrimental.”

In a related thread, a member from Minnesota asked whether influenza can spread from a mother to an unborn child. The question followed the case of a 24-year-old pregnant mother at 31-weeks gestation with a confirmed case of H1N1. She was admitted, started on ceftriaxone and azithromycin (Zithromax), transferred to the intensive care unit secondary to respiratory failure, and intubated several days later. The patient was then started on oseltamivir. The baby was delivered by caesarian section “due to decreased variability and poor BPP.”

The infant is doing well without any influenza symptoms, although H1N1 testing is pending. “Tamiflu was not started due to concerns about sodium benzoate in the preparation,” the member said. “Given the nature of this exposure, would others have treated or prophylaxed this infant?”

A respondent in Utah said there is no evidence that seasonal influenza crosses the placenta and discouraged the use of prophylaxis in premature infants. The infection can probably be prevented, the member said. Also, if the mother has been sick for several days, she will have decreasing viral shedding and will possibly have started to make antibodies. “I think the risks of Tamiflu prophylaxis outweigh the benefits,” the member continued. “I worry about the mother infecting the baby, would use contact isolation type barriers, and be very careful about having her in the NICU.”

If needed for use in infants under other circumstances, FDA’s emergency use authorization of oseltamivir offers dosing guidance.

E-mail the Emerging Infections Network.

The Emerging Infections Network (EIN) is a provider-based sentinel network designed to help the public-health community detect trends in emerging infectious diseases.

A joint project of IDSA and the Pediatric Infectious Diseases Society (PIDS) and supported by funding from the Centers for Disease Control and Prevention, EIN tracks emerging infectious diseases and keeps the public-health community up to date with issues that are currently affecting or may soon affect members’ clinical practices.The Network provides a great opportunity for members to share knowledge quickly across large geographical distances. Both IDSA and PIDS members are eligible to join. The EIN listserve allows members to discuss new disease trends and difficult cases. Click here for more information or to join EIN.

Drug Approvals, Recalls, Adverse Events Update

IDSA offers two e-mail services to help members stay informed of updates from the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA). Content normally includes a range of topics, including new drug approvals and warnings. Recent alerts have included:

• Three Reports of Oseltamivir Resistant Novel Influenza A (H1N1) Viruses (7/09)
• Intensive-Care Patients With Severe Novel Influenza A (H1N1) Virus Infection (7/10)
• Clinicians Advised to Halt Use of Propofol from Tainted Lots (7/13)
• Isentress (raltegravir) Indication Extended for the Treatment of HIV-1 Infection in Treatment-naïve Patients (7/14)
• MMWR Weekly - Neurologic Complications Associated with Novel Influenza A (H1N1) Virus Infection in Children -- Dallas, Texas, May 2009 (7/24)
• FDA Authorizes Emergency Use of Another Test for 2009 H1N1 Influenza Virus (7/24)

IDSA members can sign up for these services online. (You must be logged in to have access to this link.)

Is Your Facility Experiencing Antibiotic Shortages?
Report these to FDA and IDSA.

“Ask the Coder” Answers Critical Care Code Questions and More

Given the inherent subjectivity of picking the most appropriate current procedural terminology (CPT) service code, the answers provided through “Ask the Coder” are provided on an “as is” basis. Readers must use their own independent professional judgment in making coding decisions. The reader assumes all risks in using this information.

Earlier this month, IDSA launched the “Ask the Coder” e-mail portal, a resource to help answer tough coding questions for IDSA members and their staffs. Recent topics have included how to bill properly for critical care and prolonged services.

Medicare data indicate that the prolonged services codes are often underutilized— leading to ID physicians not being paid for the entirety of their work. (See IDSA News article.)

An IDSA member asked, “What are the requirements for using prolonged service codes (99354-99357)?”

Ask the Coder: The use of the current procedural terminology (CPT) codes 99354 through 99357 is dependent on where the service is rendered. In an office setting, you would use CPT codes 99354 and 99355. In an in-patient setting, you would use CPT codes 99356 and 99357. The supporting documentation needs to indicate how much time was spent with the patient and a brief description of what was performed during the visit. The CPT codes are time-based, and the CPT book has a grid, as well as information on the companion evaluation and management (E&M) codes.

Another IDSA member asked, “What are the requirements to bill critical care codes 99291 and 99292?”

Ask the Coder: First, the patient must meet the critical care criteria, which is a critical illness described as impairing one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition. Second, you must give this one patient constant attention. You may bill 99291 for the first hour, and for each additional 30 minutes spent with the patient you can bill a 99292. It is important to note, if you render critical care in a day, you may not bill any other E&M codes. On the other hand, if you see the patient for a regular visit earlier in the day, and then the patient becomes critical, you may bill critical care for those later services, and the original E&M service will need the -25 modifier (a significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported).  Also, you must document the time in the patient’s chart, and write a brief description indicating your involvement.

Do you have a puzzling billing and coding question? You can submit your questions using the “Ask the Coder” e-mail portal and view additional information about billing and coding by visiting www.idsociety.org/coding.htm.

Deadline for Identity Theft Policies Extended to Nov. 1

Physicians now have until Nov. 1 to set up policies to protect their patients’ identities under a rule from the Federal Trade Commission (FTC). These so-called “Red Flag Rules” require creditors—including physician practices—to protect clients’ personal identifying information, such as insurance information, from being used fraudulently. The rule had been scheduled to go into effect Aug. 1 (see the June issue of IDSA News).

Highlights from the International AIDS Society Conference in South Africa

What are top HIV/AIDS physician-scientists saying about whether to initiate antiretroviral therapy earlier? How are they responding to criticism that disease-specific programs detract from broader efforts to strengthen health systems? How can HIV/AIDS program implementers improve on efforts to prevent mother-to-child-transmission of HIV?

These were among the hotly-debated topics at the 5th International AIDS Society Conference, held earlier this month in Cape Town, South Africa. If you couldn’t make it, you can still read all about the conference —at the Center for Global Health Policy’s blog, ScienceSpeaks. The Global Center’s staff filed nearly a dozen stories, reporting on the latest policy discussions and research findings.

Find out what Eric Goosby, MD, the new U.S. Global AIDS Coordinator, and Anthony S. Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, said in response to questions about the Obama administration’s approach to global AIDS. Or read a detailed account of the presentation by Pedro Cahn, MD, past IAS president and head of the Huésped Foundation, an Argentinean AIDS organization, who offered a refreshingly candid and provocative HIV treatment update. Among other things, Cahn said a CD4 level of 350 should be the minimum threshold for antiretroviral therapy; D4T regimens are too toxic, have a lousy resistance profile, and should be dropped; and viral load testing needs to be put in place widely and urgently.

Read more about the IAS Conference and other global health news at sciencespeaks.wordpress.com, the Global Center’s blog. Recent posts include:

• A story about the surge of interest in global health studies on college campuses across the United States and how universities have responded by expanding programs that teach students about improving public health and achieving health equity around the world. Leading experts say this phenomenon presents immense opportunities, as well as fresh challenges, that academics, political leaders, and physician-scientists should seize to sustain interest.
• An analysis of the latest congressional funding proposal for global AIDS and tuberculosis programs. Earlier this month, the Senate Appropriations Committee approved only modest increases for the President’s Emergency Plan for AIDS Relief (PEPFAR) and bilateral TB programs—sums that are inadequate to address the increasing scope of these twin epidemics and that are significantly less than called for in the House version of the legislation.

Global Center Report and Briefing Highlight HIV/AIDS and TB Co-Infection

The Center for Global Health Policy published a major report on HIV/TB co-infection last month. Unveiled at a Capitol Hill briefing on June 25, “Deadly Duo: The Synergy Between HIV/AIDS & Tuberculosis” details the scope of this public health crisis and calls for an aggressive response from U.S. policymakers. To watch video of the briefing, click here for part one and here for part two.

Speakers included Diane Havlir, MD, professor of medicine at the University of California, San Francisco, and chief of the HIV/AIDS Division and Positive Health Program at San Francisco General Hospital, who also serves on the Center’s Scientific Advisory Committee; Carol Dukes Hamilton, MD, FIDSA, co-chair of the Center’s Scientific Advisory Committee and a senior director of research at Family Health International; and Rosemary Mburu with the Kenya AIDS NGOs Consortium.

IDSA, SHEA, Others Support Mandatory National Reporting of HAIs

IDSA and four other organizations are supporting a provision in a federal health reform bill that would require national reporting of healthcare-associated infection (HAIs) information. The provision would require hospitals and ambulatory surgical centers to report HAI data in order to participate in Medicare and Medicaid. Nationally, these infections claim an estimated 99,000 lives every year and cause more than $20 billion in excess medical costs.

Two aspects of the legislation were crucial to IDSA’s support: The bill specifies the Centers for Disease Control and Prevention (CDC)’s National Healthcare Safety Network as the target and repository of the HAI data, rather than calling for a new or separate system, and the legislation gives CDC the latitude to determine which pathogens should be reported and how.

IDSA, the Society for Healthcare Epidemiology of America (SHEA), the Association for Professionals in Infection Control and Epidemiology (APIC), the Council of State and Territorial Epidemiologists (CSTE), and the Trust for America’s Health (TFAH) this month sent a joint letter to Congress and issued a press release supporting the provision, which is part of a health reform bill (H.R. 3200) introduced in the U.S. House of Representatives (see President’s Message). The groups also urged Congress to include the Strategies to Address Antimicrobial Resistance (STAAR) Act (H.R. 2400) as part of the final health reform bill (see IDSA News article) to strengthen the federal approach related to antimicrobial resistance.

There is much interest on Capitol Hill in the HAI issue, and IDSA continues to monitor legislative developments and support additional funding for CDC—in particular, its National Healthcare Safety Network—and funding for related purposes.

On a related front, the Department of Health and Human Services (HHS) has launched a new federal plan to reduce HAIs (see IDSA News article). This summer, HHS is holding several meetings to solicit feedback and promote the plan, which includes prevention metrics and targets for reducing and preventing HAIs.

For more information on HAI prevention, see:

The Compendium of Strategies to Prevent HAIs in Acute Care Hospitals

5th Decennial International Conference on Healthcare-Associated Infections, March 18-22, 2010, Atlanta. Abstract submission deadline: Nov. 16.

Medicare Proposes Eliminating Payments for Consultations

The Centers for Medicare and Medicaid Services (CMS) on July 1 published a proposed rule that—if it takes effect—would eliminate payments for the outpatient and inpatient consultation codes used by many ID physicians, starting in 2010. Under the CMS proposal, physicians would instead use the “new office patient” and “initial hospital visit” codes; a new modifier would be established and used by the admitting physician to distinguish her or him from physicians who provide specialty care. The money previously allocated to consultation codes would be shifted to other evaluation & management (E&M) services, particularly in the outpatient setting.

In theory, private insurers could still allow use of the consultation codes, but in practice, many insurers follow CMS’ lead.

The proposal appears designed to provide incentives for primary care—an important priority for health care reformers. However, IDSA and other specialty societies argue that it would do so at the expense of ID and other purely cognitive specialties, and may not be cost-effective in the long run.

“The proposal fails to acknowledge the unique nature of ID consultations, which require not only time to complete an exhaustive clinical evaluation and to review medical history, but also the expertise to analyze and synthesize the medical data into meaningful recommendations that are individualized to patients’ needs,” said Larry Martinelli, MD, FIDSA, past chair of IDSA’s Clinical Affairs Committee. “Nor does the proposal account for the work ID physicians do when first evaluating critically ill hospitalized patients who are often immune-compromised, suffer from multiple organ system dysfunctions and co-morbidities, and have endured prolonged inpatient stays.”

The final rule is due out in November. In the meantime, IDSA continues to urge CMS and members of Congress not to make this change, which would perpetuate and worsen an already inequitable payment system. See IDSA’s website for information on how you can help make the case.

FDA’s New Approach to Antimicrobials in Animals Earns Support of IDSA, Others

This month, IDSA mobilized an informal coalition of 20 organizations to support the Obama administration’s new public health approach to antimicrobial use in animals. The Food and Drug Administration (FDA)’s new approach calls for phasing out the use of antimicrobials for growth promotion and feed efficiency. Announced earlier this month, the new approach also requires that other animal uses of these drugs be carried out under the supervision of a veterinarian and within the context of a valid veterinarian-client-patient relationship—which is expected to end the over-the-counter sales of tons of antimicrobial drugs annually.

The White House and FDA quickly received complaints from agricultural interests opposed to this new approach, making it important that experts from the medical, scientific, food safety, and animal health sectors come together to support this policy shift. The groups—including IDSA—voiced their support in a joint letter to the Obama administration. The groups also urged FDA to make the new policy mandatory, retroactive to already-approved drugs, and enforceable. IDSA and the Trust for America’s Health (TFAH) also issued a press release applauding the administration’s leadership on this politically charged issue.

Other IDSA advocacy efforts include:

• IDSA, the HIV Medicine Association, and the Center for Global Health Policy are strongly urging Congress to fully repeal the 20-year-old ban on federal funding for needle exchange programs. The House passed an appropriations bill on July 24 that includes a partial repeal of the ban. Unfortunately, the House bill would limit the areas where needle exchange programs can operate, hindering urban areas in implementing these programs where they are most needed. The Senate appropriations bill does not include language concerning repeal of the ban. In a press release and several letters, IDSA, HIVMA, and the Center called on the full Congress to repeal the ban without restrictions. The organizations will work to include a full ban in the final appropriations measure.
• In a letter, IDSA responded to a draft health care reform bill (see President’s Message). The Society addressed concerns about physician payment reform, supported expanding access to federally recommended vaccines, and called for offer evidence-based wellness and prevention services, such as routine HIV testing. IDSA also urged lawmakers to include the Strategies to Address Antimicrobial Resistance (STAAR) Act (see IDSA News article) and legislation to improve access to home-infusion therapy in the final version of the committees’ bill. IDSA also signed onto a separate letter that urged the inclusion of medical liability reform within the context of health care reform legislation.  (For additional IDSA comments on health reform, click here.)  
• IDSA, HIVMA, and the Global Center support the Obama administration’s move to lift the nation’s ban on travel and immigration to the United States by HIV-positive individuals. The Centers for Disease Control and Prevention (CDC) has proposed removing HIV from the list of diseases that classified the infection as a “communicable disease of public health significance.” CDC is seeking public comment through Aug. 17 at this website.
• In a joint letter, IDSA, the Society for Healthcare Epidemiology of America (SHEA), and the Association for Professionals in Infection Control and Epidemiology (APIC) urged that CDC guidance for novel H1N1 infection control in health care settings be revised based on the evolving science. In June, IDSA and APIC endorsed a SHEA position statement that also addressed this issue (see IDSA News article).

Congratulations, New IDSA Fellows!

Fellowship in IDSA honors individuals who have achieved professional excellence and provided significant service to the profession. The following members were elected to fellowship this year:

Adaora Adimora, MD, FIDSA
University of North Carolina School of Medicine, Chapel Hill, NC

Brian Agan, MD, FIDSA
Uniformed Services University of Health Sciences, Bethesda, MD

George Alangaden, MD, FIDSA
Wayne State University, Detroit, MI

Paul G. Auwaerter, MD, FIDSA
Johns Hopkins University School of Medicine, Baltimore, MD

Robin K. Avery, MD, FIDSA
Cleveland Clinic Foundation, Cleveland, OH

Arlene D. Bardeguez, MD, MPH, FIDSA
UMDNJ-New Jersey Medical School, Newark, NJ

Dan H. Barouch, MD, FIDSA
Beth Israel Deaconess Medical Center, Brookline, MA

Katherine L. Baumgarten, MD, FIDSA
Ochsner Clinic Foundation, New Orleans, LA

Richard Bax, MD, FIDSA
Viropharma Limited, Berkshire, England

Joseph A. Bick, MD, FIDSA
California Medical Facility, Davis, CA

Virginia M. Bieluch, MD, FIDSA
Hospital of Central Connecticut, New Britain, CT

Karen Bloch, MD, FIDSA
Vanderbilt University, Nashville, TN

Suresh B. Boppana, MD, FIDSA
University of Alabama at Birmingham, Birmingham, AL

Patricia D. Brown, MD, FIDSA
Wayne State University School of Medicine, Detroit, MI

Jon B. Bruss, MD, FIDSA
ACHAOGEN, Inc., South San Francisco, CA

Joan Butterton, MD, FIDSA
Merck Research Laboratories, Boston, MA

Rafael E. Campo, MD, FIDSA
University of Miami School of Medicine, Miami, FL

Mary Caserta, MD, FIDSA
University of Rochester School of Medicine, Rochester, NY

Corey Casper, MD, FIDSA
University of Washington, Seattle, WA

Raymond Y. Chinn, MD, FIDSA
Sharp Metropolitan Medical Campus, San Diego, CA

Jonathan A. Cohn, MD, FIDSA
Wayne State University School of Medicine, Detroit, MI

Melba I. Colon-Quintana, MD, FIDSA
Universidad Central del Caribe School of Medicine, Bayamon, Puerto Rico

Beverly Connelly, MD, FIDSA
Cincinnati Children's Hospital, Cincinnati, OH

Judith S. Currier, MD, FIDSA
UCLA-Care Center, Los Angeles, CA

Carlos A. Diazgranados, MD, FIDSA
Emory University School of Medicine, Atlanta, GA

Daniel J. Diekema, MD, FIDSA
University of Iowa, Carver College of Medicine, Iowa City, IA

Eileen F. Dunne, MD, FIDSA
Centers for Disease Control and Prevention, Decatur, GA

Getachew Feleke, MD, FIDSA
Nassau University Medical Center, East Meadow, NY

Michael J. Gehman, DO, FIDSA
Guthrie Clinic/Robert Packer Hospital, Sayre, PA

Marshall J. Glesby, MD, FIDSA
Weill Cornell Medical College, New York, NY

Steven M. Gordon, MD, FIDSA
Cleveland Clinic Foundation, Cleveland, OH

Barbara M. Gripshover, MD, FIDSA
Case Western Reserve University, Cleveland, OH

Roy M. Gulick, MD, FIDSA
Weill Cornell Medical College, New York, NY

Kamal A. Hamed, MD, FIDSA
Novartis, Flemington, NJ

Daniel H. Havlichek Jr., MD, FIDSA
Michigan State University, East Lansing, MI

Lisa Hirschhorn, MD, MPH, FIDSA
Department of Global Health and Social Medicine - Harvard Medical School, Newton, MA

Daniel Hoft, MD, PhD, FIDSA
St. Louis University School of Medicine, St. Louis, MO

William Koch, MD, FIDSA
Virginia Commonwealth University, Richmond, VA

David M. Koelle, MD, FIDSA
University of Washington, Seattle, WA

Janak Koirala, MD, FIDSA
SIU School of Medicine, Springfield, IL

Camille N. Kotton, MD, FIDSA
Massachusetts General Hospital, Boston, MA

Steven I. Marlowe, MD, FIDSA
Atlanta Clinical Care and Specialty Research, Atlanta, GA

Daniel P. McQuillen, MD, FIDSA
Lahey Clinic Center for Infectious Disease, Burlington, MA

Meryl H. Mendelson, MD, FIDSA
Novartis Pharmaceuticals, East Hanover, NJ

Joshua P. Metlay, MD, PhD, FIDSA
University of Pennsylvania, Philadelphia, PA

Robert S. Miller, MD, FIDSA
Walter Reed Army Institute of Research, Potomac, MD

Michele I. Morris, MD, FIDSA
University of Miami Miller School of Medicine, Miami Beach, FL

Cora E. Musial, MD, PhD, FIDSA
Carle Clinic Association, Urbana, IL

Eleftherios Mylonakis, MD, FIDSA
Massachusetts General Hospital, Boston, MA

Marguerite A. Neill, MD, FIDSA
Alpert Medical School, Brown University, Pawtucket, RI

Roger E. Nieman, MD, FIDSA
Abington Memorial Hospital, Abington, PA

Daniel Nixon, PhD, FIDSA
Virginia Commonwealth University, Richmond, VA

Philip J. Norris, MD, FIDSA
Blood Systems Research Institute, San Francisco, CA

Naomi P. O'Grady, MD, FIDSA
National Institutes of Health, Bethesda, MD

Claire B. Panosian, MD, FIDSA
David Geffen School of Medicine at UCLA, Los Angeles, CA

Leslie J. Parent, MD, FIDSA
Penn State College of Medicine, Hershey, PA

Andrew J. Pollard, PhD, FIDSA
University of Oxford, Oxford, OH

Gregory K. Robbins, MD, FIDSA
Massachusetts General Hospital, Boston, MA

Robert G. Sawyer, MD, FIDSA
University of Virginia, Charlottesville, VA

Richard Schwartz, MD, FIDSA
Advanced Pediatrics, Vienna, VA

Jose Sifuentes-Osornio, MD, FIDSA
Instituto Nacional Ciencias Medicas y Nutricion, Mexico City, Mexico

Valerie E. Stone, MD, FIDSA
Harvard Medical School/Massachusetts General Hospital, Boston, MA

Sybil Tasker, MD, FIDSA
Naval Health Research Center, Cairo, Egypt

Chloe Thio, MD, FIDSA
Johns Hopkins University, Baltimore, MD

Barbara Trautner, MD, FIDSA
Baylor College of Medicine, Houston, TX

Steven Bruce Williams, MD, FIDSA
University of New Mexico Health Sciences Center, Albuquerque, NM

Faheem Younus, MD, FIDSA
Upper Chesapeake Health, Perry Hall, MD

More information about fellowship in IDSA and an application are available online.

Welcome, new members!

Members

Bergeron, Marc, PhD
Brune, Paul, MD
Dasgupta, Anjali, MD
Drummelsmith, Jolyne, PhD
Heaton, Penny, MD
Lane, Garry, MD
Lane, Stacy, DO
Nandu, Vijay, MD
Rodriguez-Diaz, Ana, MD
Sanderson, Susan, FNP,MSN
Spear, Joel, MD
Suleman Moosa, Mahomed Yunus, MD, PhD

Associates

Burch, Mary, PharmD
Chun, Helen, MD
DrIver, Yvette, PharmD
Farias, Seferino, MS
Gold, Mark, PhD
Kusan, Karuna, MD
Matthews, Tracy, BSN, MHA
Morris, Wistar, MBA
Persaud, Roberta, MD
Sherer, Renslow, MD
Watts, Chris, MD
Wise, William, DO

Members-in-Training

Abualfoul, Ahmed, MD
Ahmad, Waseem, MD
Ameneni, Shashikala, MD
Ashfaq, Ahmad, MD
Ashraf, Muhammad Salman, MD
Atia, Antwan, MD
Azis, Leyla, MD
Bannan, Ciaran, MB, DTM&H, MRCP
Bakker, Richard, MD, PhD
Bhadelia, Nahid, MD
Bharadwaj, Ramesh, MD
Bhusal, Yogesh, MD
Blattman, Negin, MD
Bocchini, Claire, MD
Bolaris, Michael, MD
Boritz, Eli, MD, PhD
Bosch, Wendelyn
Bosques-Rosado, Marisel, MD
Brizendine, Kyle, MD
Cabada, Miguel, MD
Choo, Hoo Feng, MD
Christensen, Diana, MD
Chu, Angel, MD
Chu, Helen, MD
Coffin, Phillip, MD, MPA
Crowe, James, MD
Dallapiazza, Michelle, MD
Davila, Samuel, MD
De La Rorg, Benjamin, MD
Delman, Mark, MD
Delva, Guesly, MD
Dharan, Nila, MD
Doernberg, Sarah, MD
Dumford, Donald, MD
Eisenberg, Nell, MD
Emaleu, Serge Blaise, MD
Ermel, Aaron, MD
Farel, Claire, MD, MPH
Gandhi, Roshni, MD
Geng, Elvin, MD
Gilpin, Nicholas, DO
Goodrich, Suzanne, MD
Gray, Jacob, MD
Green, Julianne, MD, PhD
Gulia, Jyoti, MD, MPH
Haas, Douglas, MD
Harting, Julie, PharmD
Hasan, Anjum, MD
Hayakawa, Kayoko, MD, PhD
Irizarry-Acosta, Melina, MD
Jagannathan, Prasanna, MD
Jain, Ruchika, MD
Jjingo, Caroline, MD
Johnson, James, MD
Johnson, Dan, MD
Jones, Jessica, MD
Joshi, Vishal, MD
Karmon, Sharon, MD, MPH
Kaur, Amandeep, MD
Kilayko, Mary Clarisse, MD
Knackmuhs, Elizabeth, MD
Kohli, Anita, MD
Lancioni, Christina, MD
Levy, Dana, MD
Li, Aldon, MD
Liang, Stephen, MD
Lin, Leyi, MD
Liscynesky, Christina, MD
Marcos, Luis, MD
Marquez, Lucila, MD
Martin, Andrew, MD
McDermott, Rena, MD
McNeil, Jonathan, MD
McNelley, Erin, MD
Menajovsky, Jose, MD
Miko, Benjamin, MD
Minnema, Brian, MD
Morgan, Ana Elizabeth, MD
Nayak, Seema, MD
Nichol, Aran, MD
Nott, Sujatha, MD
Omikunle, Adebomi, MD
Oppenheimer, Ana Paula, MD
Osinusi, Olukemi, MD, MPH
Oyer, Ryan, MD
Patel, Diixa, MD
Pham, Huan, MD
Pierce, Virginia, MD
Pierre, Cassandra, MD
Polyak, Christina, MD, MPH
Quezada, Nestor, MD
Rao, Kavitha, MD
Rappo, Urania, MD
Rii, Joyce, DO
Roig, Ingrid, MD
Rosenberg, Oren, MD, PhD
Rotjanapan, Porpon, MD
Rowan, Sarah, MD
Rzepka, Robert, MD
Salamera, Julius, MD
Shah, Javeed, MD
Shapiro, Craig, MD
Simpson, Tameka, DO
Strollo, Stephanie, MD
Subhi, Ahmad, MD
Subramanian, Anuradha, MD
Sullivan, Seth, MD, MPH
Sural, Preethi, MD
Swaminathan, Subramanian, MD
Syed, Uzma, DO
Taimur, Sarah, MD
Thet, Zeyar, MD
Torrento, Marlon, MD,MS
Torres, Katherine, DO
Trevillyan, Janine, MBBS
van der Heijden, Yuri, MD
Vodzak, Jennifer, MD
Wallihan, Rebecca, MD
Watson, Michael, MD, PhD
Westley, Benjamin, MD
Widmer, Kyle, MD
Williams, Susan, MD
Wilson, Eleanor, MD
Yeo, Kee Thai, MD
Young, Heather, MD
Young, Daniel, MD
Youssef, Dima, MD
Zadroga, Rebecca, MD
Zhao, Hui, MD

Create Your Personal Annual Meeting Itinerary with the Online Program Planner

Before you head to Philadelphia for the 47th Annual Meeting of IDSA, Oct. 29-Nov. 1, check out the sessions and plan your schedule with the Online Program Planner. The planner enables you to search for individual presentations or sessions and create a personal itinerary for the meeting.

Ways to Search

• search by keywords using the search box
• use the advanced search engine to find more specific results for a particular session type, session title, presentation number, abstract title, keyword, author’s last name, institution, or session date/time
• browse to explore IDSA presentations by category, session type, and date

Personalized Itineraries

However you view the sessions and presentations, you can add items to your personalized itinerary. Use My Itinerary to create your own schedule of meetings and personal events.

The Online Program Planner is available now. For more information about the Annual Meeting, visit the Annual Meeting web page.

How to Manage Information Overload

Are you struggling to keep up with the information overload in infectious diseases? IDSA offers several services to help time-strapped ID professionals keep up to date in a concise manner:

ID News Clips
This daily free news clipping service is provided to keep you apprised of information about infectious diseases that is available on the Internet. Subscribers receive a daily e-mail with ID headlines from the lay press, with links to full text articles on external websites. This service helps you keep up with the information your patients and the public are reading. Click here to view a sample.

CDC Health Alert Network Service
This service forwards Health Alert Network messages from the Centers for Disease Control and Prevention (CDC) about outbreaks, bioemergencies, and other timely events. It is intended for members who do not receive these messages from other sources. Click here to view a sample.

FDA Alert Forwarding Service
This service forwards ID-related messages from the Food and Drug Administration (FDA) on label changes, adverse events, newly approved drugs, and other safety information on FDA-approved drugs and biologics. Click here to view a sample.

All these services are provided to you as an IDSA member at no charge. To subscribe, simply click here.

By subscribing, you agree to receive e-mail messages from IDSA. You can unsubscribe at any time.

IDSA Website Offers Practical Tips on Coding, Other Practice Management Issues

Even if you missed the recent Clinical Practice Meeting, you can still see helpful presentations such as  “The Nuts and Bolts of E/M Coding: A Detailed Look at the Codes Used by ID Specialists,” with Barb Pierce, CCS-P, ACS-EM. During this session, participants went through real-life consultations and learned how an auditor looks at your claims.

The audio-synced slides from this meeting are available for purchase from Sound Images.

The IDSA website also has resources on billing and coding, quality improvement initiatives, negotiating compensation, dealing with audits, and the Recovery Audit Contractors program. (You must be logged in to access these links.)