IDSA News - February 2012
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CDC Guidance for Influenza Antivirals Remains Unchanged
A recent review of randomized clinical trial data for influenza neuraminidase inhibitor antiviral medications published by the Cochrane Collaboration, and two related commentaries published in the British Medical Journal (available here and here), have raised questions about the value of antiviral medications for the prevention and treatment of influenza. After reviewing the available evidence, the Centers for Disease Control and Prevention (CDC) continues to recommend the use of the neuraminidase inhibitor antiviral drugs (oral oseltamivir and inhaled zanamivir) as an important adjunct in influenza prevention and treatment. Read CDC’s online statement for more information.
A meta-analysis review of observational studies of influenza antiviral treatment was published this week in the Annals of Internal Medicine. Analyses focus on hospitalized patients and pregnant women, where there are no good randomized trial data, and provide strong support for CDC and IDSA recommendations to treat high-risk patients and to begin therapy early.
Medicare Website Reports Hospital CLABSI Rates
Medicare’s “Hospital Compare” consumer website now includes data on central line-associated bloodstream infection (CLABSI) rates reported from hospital ICUs to the Centers for Disease Control and Prevention (CDC)’s National Healthcare Safety Network. See CDC’s “Safe Healthcare” blog and Medicare’s press release for more on the addition of the data to the website, announced earlier this month.
ACIP Recommends Tdap for All Adults, Including Those 65 and Older
Earlier this month, the federal Advisory Committee on Immunization Practices (ACIP) recommended the Tdap (tetanus-diphtheria-acellular pertussis) vaccine for all adults, including those aged 65 and older. Previously, the vaccine was recommended for those 19 through 64 years old and for adults 65 and older in close contact with young infants. The new guidance calls for all adults 19 and older who have not received the Tdap vaccine already to be given a single dose, according to IDSA’s ACIP liaison, Kathleen M. Neuzil, MD, MPH, FIDSA.
The committee also heard updates on the current influenza season, which is fairly mild at present, although there is increased activity in certain areas. The new 13-valent pneumococcal conjugate vaccine (PCV13), recently approved for use in adults, was also discussed, but no recommendations were made.
ACIP recommendations become official once approved by the CDC and published in MMWR.
Drug Approvals, Recalls, Adverse Events Update
IDSA offers two email 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 includes a range of topics, including new drug approvals and warnings. Recent alerts have included:
IDSA members can sign up for these services online. (You must be logged in to have access to this link. Once logged in, click on the “My Alerts” tab to subscribe to the alerts. To subscribe, check the appropriate boxes to receive CDC’s Health Alert Network (HAN) messages and/or alerts from FDA, and provide your email address and name where indicated.)
Is Your Facility Experiencing Antibiotic Shortages?
IDSA members are urged to report drug shortages directly to FDA and to copy IDSA staff at firstname.lastname@example.org.
Medicare Physician Payment Cuts Delayed for 10 Months
Earlier this month, Congress passed a measure delaying a 27-percent cut in Medicare physician payments for 10 months, through the end of 2012. The payment cuts had been scheduled to go into effect March 1, 2012, when a previous short-term fix would have expired. Physicians will continue to face periodic payment cuts, limiting patient access to physician services, unless Congress fixes the flawed Sustainable Growth Rate (SGR) payment formula, used to calculate Medicare payments to physicians.
Interview Series: CDC’s Role in Global HIV and TB
Learn about the role of the Centers for Disease Control and Prevention in HIV and tuberculosis-related global activities in a series of conversations with CDC officials—including Scott Dowell, MD, MPH; Kayla Laserson, PhD; and John Vertefeuille, PhD—on Science Speaks, the blog of the Center for Global Health Policy.
More recent news from Science Speaks:
Experts Highlight Role of Prevention Interventions in Global AIDS Fight
Read more on Science Speaks about combination HIV/AIDS prevention interventions, evidence of their effectiveness, and their role in the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) in developing countries, from a February briefing on Capitol Hill hosted by the Foundation for AIDS Research (amfAR), the Center for Global Health Policy, and the PEPFAR program.
More recent news from Science Speaks:
PEPFAR Takes Hit in Obama’s FY2013 Budget
President Obama’s budget proposal for the 2013 fiscal year includes $1.65 billion in funding—an increase of 26.9 percent—for the Global Fund to Fight AIDS, Tuberculosis, and Malaria to meet the U.S pledge of $4 billion over three years. But the welcome increase comes at the expense of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), which would be cut by $542.9 million—almost 13 percent. Learn more about the budget on the Science Speaks blog.
More recent news from Science Speaks:
Obama’s FY2013 Budget Mixed Bag for ID, HIV/AIDS
Responding to President Obama’s proposed budget for the 2013 fiscal year, IDSA raised concerns earlier this month about proposed cuts in immunization programs, state and local public health preparedness, and the Prevention and Public Health Fund, as well as policies that discourage research. IDSA’s full response is online.
The president’s budget makes important investments in domestic HIV programs but falls short in committing the resources necessary to put us on course to end AIDS globally, HIVMA noted in a statement. More analysis of the budget’s implications for the global response to HIV is available on Science Speaks, the blog of the Center for Global Health Policy.
HHS Advisory Group Recommends Voluntary Measures to Boost HCW Influenza Vaccination
The National Vaccine Advisory Committee, an advisory group to the Department of Health and Human Services, recently recommended a set of voluntary measures to increase influenza vaccination rates among health care workers (HCWs), stopping short of urging mandatory vaccination. Employers, however, should consider mandatory vaccination policies if facilities fall short of immunization goals using voluntary measures, the committee also recommended.
IDSA, joined by the Pediatric Infectious Diseases Society and the Society for Healthcare Epidemiology of America, had earlier urged the committee to strongly recommend mandatory influenza vaccination policies for all HCWs. The comments are online (PDF).
Check Out “My IDSA” for Latest Member News
Find the latest membership news on “My IDSA” on the IDSA website, including new IDSA members, how to get a 20 percent discount on Oxford University Press book titles, and upcoming deadlines for IDSA awards. Log in with your user ID and password, and look under the “My Membership News” tab.
Are you a member on the move? Do you know someone who is? Contact Stephanie Cox at email@example.com so that we can announce it to our membership.
CDC Lyme Disease Webinar: CME Credit Available
Join Alison Hinckley, PhD, an epidemiologist with the National Center for Emerging and Zoonotic Infectious Diseases at the Centers for Disease Control and Prevention (CDC), for a free Clinician Outreach and Communication Activity call/webinar on Lyme disease, 2-3 pm EST, March 6. Dr. Hinckley will review the epidemiology of Lyme disease, early signs and symptoms, appropriate use of diagnostics, recommended treatment guidelines, and prevention practices. Continuing medical education is available.
Visit CDC’s website for more details. To participate by phone, dial 888-790-6180 and use passcode 1281914. To join online, access this link. The materials may also be downloaded after the webinar.
Adolescent Vaccination Education Materials Available
An updated adolescent vaccination fact sheet for health care providers is available from the Centers for Disease Control and Prevention (CDC). The four-page fact sheet (PDF) includes an overview of adolescent immunization recommendations and tips to help ensure teens and preteens are fully vaccinated.
Posters, fact sheets, and flyers to educate parents about adolescent vaccinations are also available, in multiple languages, on CDC’s website as print-ready files. Hard copies can also be ordered free of charge.
From the President:
How Is Antimicrobial Resistance Affecting Your Patients?
By sharing your front-line perspectives on how antimicrobial resistance is impacting your ability to care for patients, you can make a big difference by raising awareness about the need to address growing resistance and the lack of antimicrobial research and development.
Recently I treated a previously healthy 24-year-old graduate student who was brought to our emergency room. She could not keep fluids down, her blood pressure was abnormally low, she was terribly weak, and she had a fever.
Several days before, she had been treated at an urgent care center for symptoms of a urinary tract infection, but the oral antibiotic she was given (ciprofloxacin) wasn’t working. We admitted the patient to the ICU, where she was intubated, and we replenished her fluids. Her chest x-ray showed severe lung disease, consistent with acute respiratory distress syndrome. Blood and urine cultures identified the culprit: A multiply resistant strain of extended-spectrum beta lactamase (ESBL)-producing E. coli.
Fortunately, we were able to save her using a few of the remaining and effective antibiotics still left in our arsenal. She improved, was able to leave the ICU after a few days, and eventually went home, where she received IV antibiotics for another seven days.
As IDSA members well know, this patient was lucky. As resistance rates continue to rise, and the antimicrobial development pipeline remains dry, even common, everyday infections are becoming harder to treat and are increasingly life threatening.
The next several months offer a critical window of opportunity in Washington to help address the lack of new antimicrobial development. Interest on Capitol Hill is growing, hearings have been held, and an important bill, the Generating Antibiotics Incentives Now (GAIN) Act, has been introduced in the U.S. House and Senate. IDSA is doing everything it can on many fronts on this issue. But to build on this momentum and get legislation passed in 2012, we need you, our members, to be the difference makers.
How can you help? Share a brief vignette or anecdote, like mine above, showing how antimicrobial resistance is impacting your ability to care for patients. Just 200 words or so in length, and without any patient identifying information, these accounts are powerful tools that educate policymakers and drive home the need for action. Also, visit IDSA’s “Take Action” webpage to send messages to your representatives in Congress and urge your colleagues to do the same. Stay tuned for other ways to make sure the voice of ID specialists is heard on this critical issue.
The lack of antimicrobial development coupled with the rise in drug resistance is a growing crisis that threatens patients’ lives and the very foundations of modern medical care. IDSA members know this all too well. By sharing your front-line perspectives and participating in other advocacy efforts, you can make a big difference. Please start today.
For more on IDSA’s advocacy efforts in this area, see the related article in this issue.
IDSA Urges Congress, FDA to Boost Antibiotic R&D
IDSA is working to address drug resistance and the dwindling antimicrobial research and development pipeline on multiple fronts.
IDSA is working to address drug resistance and the dwindling antimicrobial research and development pipeline on multiple fronts. Recent activities include:
- IDSA led a coalition of 50 organizations representing patients, providers, health systems, veterans, women and children’s health, seniors, and other stakeholders urging Congress to include economic incentives for antimicrobial development in legislation related to the Food and Drug Administration (FDA) (see letter (PDF)). The Society will continue to engage Congress as this legislation, one of the few “must-pass” bills this election year, moves forward.
- As Congress considers federal funding for the 2013 fiscal year, IDSA will seek specific language in appropriations bills to help strengthen the nation’s response to antimicrobial resistance (and other ID priorities such as immunizations) by providing direction to federal agencies, in addition to calling for sufficient ID/HIV funding (see press release).
- IDSA continues to urge FDA to quickly issue clear guidance to industry on anti-infective clinical trial designs. Collaborations with FDA have included workshops, advisory committee meetings, and an effort with the Foundation for the National Institutes of Health that brings together scientists from FDA, NIH, IDSA, industry, and academia (see press release). The goal: develop new regulatory standards for judging the efficacy of antibiotics in trials for therapies for skin infections and community-acquired bacterial pneumonia.
- James Johnson, MD, FIDSA, a member of IDSA’s Antimicrobial Resistance Work Group, will represent IDSA at two upcoming congressional briefings focused on the use of antibiotics in animal agriculture. The briefings are titled “The Science Is Clear: Inappropriate Antibiotic Use in Animal Agriculture Threatens Public Health.”
To learn more, including details about IDSA’s 10 x ’20 initiative, which calls for the development of 10 new systemic antibiotics by 2020, and other antimicrobial resistance policy efforts, visit the Society’s website. To learn what you can do to help, see “From the President” in this issue.
IDWeek 2012 Now Accepting Abstract Submissions
Submit your abstracts now for IDWeek 2012, the first-ever combined meeting of IDSA, HIVMA, the Society for Healthcare Epidemiology of America (SHEA), and the Pediatric Infectious Diseases Society (PIDS), Oct. 17–21, 2012, in San Diego. The deadline is May 11.
Submit your abstracts now for IDWeek 2012, the first-ever combined meeting of IDSA, HIVMA, the Society for Healthcare Epidemiology of America (SHEA), and the Pediatric Infectious Diseases Society (PIDS), taking place Oct. 17-21, 2012, in San Diego. The deadline for submitting abstracts is May 11.
Numerous awards and travel grants are available. IDWeek will also provide multiple opportunities to have your research reviewed by colleagues and leaders in the field, including oral and poster presentations, poster discussion rounds led by thought-leaders, and IDWeek-sponsored press conferences. Top abstracts in various categories will be featured throughout the meeting sessions. Fellows in training are particularly encouraged to submit their best research.
Subject categories for abstract submissions include antimicrobial resistance, diagnostics, global health, travel medicine, HIV/AIDS and other retroviruses, adult and pediatric vaccines, clinical mycology, infection epidemiology and prevention, outbreak investigations, pediatric and perinatal infections, and virology. The complete subject category list is online.
For more information, or to submit an abstract to IDWeek, visit www.idweek.org/abstracts-landing.
IDSA Journal Club
This month: Studies investigating linezolid versus dose-optimized vancomycin for MRSA nosocomial pneumonia; CMV infection in transplant recipients and the incidence of antiviral resistance; anti-NMDAR encephalitis and the California Encephalitis Project; reversion of positive QuantiFERON-TB results to negative in low-risk HIV-infected patients; and PFC exposure and childhood antibody response.
In this feature, a panel of IDSA members identifies and critiques important new studies in the current literature that have a significant impact on the practice of infectious diseases medicine.
Click here for the previous edition of Journal Club. For a review of other recent research in the infectious diseases literature, see “In the Literature,” by Stanley Deresinski, MD, in each issue of Clinical Infectious Diseases.
Linezolid Versus Dose-Optimized Vancomycin for MRSA Nosocomial Pneumonia
Reviewed by Ed Dominguez, MD
A decade ago, two large, prospective trials found that linezolid was non-inferior to fixed-dose vancomycin for the treatment of nosocomial pneumonia. However, post hoc analysis revealed that nosocomial pneumonia from methicillin-resistant Staphylococcus aureus (MRSA) responded “significantly” better in linezolid recipients. In the March 1 issue of Clinical Infectious Diseases, researchers describe the first randomized clinical trial exclusively designed to compare the efficacy and mortality of linezolid versus dose-optimized vancomycin for MRSA nosocomial pneumonia.
From October 2004 to January 2010, 1,184 intent-to-treat patients were enrolled in the study; 348 comprised the per protocol population (172 linezolid and 176 vancomycin recipients). The two study groups were demographically similar. Ventilator-associated pneumonia was present in over 60 percent of patients; the remainder had either hospital-acquired or health care-associated pneumonia. Cure at the end of study (EOS) was found in 57.6 percent of linezolid and 46.6 percent of vancomycin recipients (P=.042). Ironically, the difference lost significance if each clinical entity was evaluated independently. Microbiologic success was similar at EOS: 58.1 percent in linezolid and 47.1 percent in vancomycin recipients. Importantly, while bacteremia was present in 5.2 percent of linezolid and 10.8 percent of vancomycin recipients, all bacteremic patients were cured.
In the modified intent-to-treat population (448 patients), nephrotoxicity was seen in 8.4 percent of linezolid and 18.2 percent of vancomycin recipients. In the vancomycin group, nephrotoxicity correlated with higher vancomycin troughs on day three of study. Anemia was more common in the vancomycin group (19.3 percent vs. 18.1 percent) and thrombocytopenia in the linezolid group (16.3 percent vs. 13.2 percent). Finally, all-cause 60-day mortality in this same population was 28.1 percent in linezolid and 26.3 percent in vancomycin recipients.
Is this the end of the controversy? Hardly. While an accompanying editorial touts the merits of this much anticipated study, it also urges caution, citing a recent outbreak of linezolid-resistant S. aureus in an ICU.
(Wunderink et al. Clin Infect Dis. 2012;54 (5): 621-629 and Torres, Antoni. Clin Infect Dis. 2012;54 (5): 630-632.)
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Preventing CMV Infection in Transplant Recipients and the Incidence of Antiviral Resistance
Reviewed by Sheila Mitsuma, MD
Cytomegalovirus (CMV) infection is one of the most commons complications of solid-organ transplantation. Seronegative patients who receive organs from seropositive donors (D+/R-) are at highest risk for developing CMV viremia as well as antiviral resistance. In the January 2012 issue of the American Journal of Transplantation, researchers analyzed 112 D+/R- renal transplant recipients who received either prophylactic or preemptive therapy, the two most commonly used approaches for preventing CMV following organ transplantation.
Thirty-two were treated prophylactically with valganciclovir for three months following transplantation, and 80 were monitored for the emergence of CMV viremia at regular intervals for the first year following transplant. The latter were treated with either ganciclovir or valganciclovir when CMV was detected at a level of 2,000 copies/ml or greater.
Consistent with prior studies, the incidence of CMV viremia was higher in the preemptive group (60 percent v. 34 percent, p = 0.02), though rates of symptomatic viremia and tissue-invasive disease did not differ significantly. Treatment failure, defined as continued viremia eight weeks following the start of therapy, was higher in the preemptive group (31 percent v. 3 percent, p = 0.001). Notably, rates of antiviral drug resistance were higher in the preemptive group (16 percent v. 3 percent, p = 0.05). The only risk factor associated with resistance was peak viral load; 75 percent of patients with a peak viral load over 180,000 copies/ml developed resistance. Rates of graft survival and acute rejection were not associated with resistance; however, the one-year estimated glomerular filtration rate (eGFR) was lower in those with resistant CMV.
The authors conclude that post-transplant prophylaxis with valganciclovir for CMV prevention is not associated with an increased risk of antiviral drug resistance. The increased rates of antiviral resistance found in the preemptive group may be due to suboptimal levels of the drug during periods of rapid viral replication, the authors note. Though a single-center retrospective study, this work reminds us that antiviral exposure is not the sole determinant in the development of resistance and that the kinetics of viral replication also plays a critical role.
(Couzi et al. Am J Transplantation 2012;12: 202–209.)
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Anti-NMDAR Encephalitis: The Most-Diagnosed Cause of Encephalitis among Young Individuals in the California Encephalitis Project
Reviewed by Christopher J. Graber, MD, MPH
An article recently published online in Clinical Infectious Diseases summarizes the experience of the California Encephalitis Project (CEP) in diagnosing previously undiagnosed encephalitis among those aged 30 and younger in California and concludes that the CEP’s most common encephalitis diagnosis was in fact a non-infectious entity: autoimmune anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis.
The CEP accepts blood and cerebrospinal fluid (CSF) samples from immunocompetent patients hospitalized for encephalopathy with at least one clinical or diagnostic finding of fever, seizure, focal neurologic finding, CSF pleocytosis, electroencephalographic (EEG) alteration, or neuroimaging abnormality. From 2007 to 2011, the CEP was referred 761 cases among patients aged 30 and younger. A diagnosis was made by the CEP in 79 cases: anti-NMDAR in 32, enterovirus in 30, herpes simplex type 1 in seven, varicella zoster virus in five, and West Nile virus in five. Patients diagnosed with anti-NMDAR encephalitis were typically ≤18 years of age (65 percent), female (75 percent), and more likely to have a movement disorder, seizures, language dysfunction, psychosis, and EEG alterations than those diagnosed with viral etiologies. Autonomic instability was exclusively seen in 47 percent of anti-NMDAR encephalitis patients.
Anti-NMDAR encephalitis, first recognized in 2007, was thought to target primarily young adult females, often with associated ovarian teratomas, but it has also been described in men or children who typically present without any identifiable tumor. Death is uncommon, and while approximately 75 percent of patients will respond completely to tumor removal and/or immunotherapy (corticosteroids, intravenous immunoglobulin, plasmapheresis, rituximab, and/or cyclophosphamide), approximately 25 percent may have residual cognitive and motor deficits. Relapses can occur in 25 percent of patients, typically those without tumors or those who are suboptimally treated with immunotherapy. Diagnosis can be made via detection of antibodies specific to the NR2B- and NR2A-containing heteromers of the N-methyl-D-aspartate receptor in the serum or cerebrospinal fluid.
Recognition of the clinical and diagnostic findings of this emerging syndrome will be important in determining its true incidence in the population at large and in guiding effective therapy.
(Gable et al. Clin Infect Dis. 2012; doi: 10.1093/cid/cir1038. published online Jan. 26, 2012)
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Reversion of Positive QuantiFERON-TB Results to Negative in Low-Risk HIV-Infected Patients
Reviewed by Nina Kim, MD, MSc
Since its approval in 2007, the use of the interferon-γ release assay for tuberculosis (TB), QuantiFERON-TB Gold (QFT), has become more widespread and has supplanted TB skin testing (TST) for the detection of latent TB in some settings. QFT requires only a single patient visit and provides an objective result. Unfortunately, this result can be subject to poor reproducibility as serial testing in health care workers has shown. A retrospective study in the Feb. 1 issue of Clinical Infectious Diseases suggests this variability in QFT testing may also be seen in a subset of HIV-infected patients, a population at greater risk of TB progression.
The HIV clinics at Denver Health and University of Colorado switched from TST to QFT testing in 2009. With routine testing of 1,364 HIV-infected patients during their first year, 94 (6.9 percent) had positive QFT results. Of these, 36 (38.3 percent) had risk factors for TB – 34 were born outside the U.S. Of the remainder, repeat QFTs were sent on 49 patients a median of 40.5 days after the first test. Of these 49 positives, 35 (71.4 percent) reverted to negative on repeat testing. Reversion occurred across all strata of initial interferon-γ response, although fewer reversions were seen in higher levels further from the cutoff value. Reversions were much more likely to occur in those patients who were born in low TB-endemic countries (odds ratio 7) and those with no identifiable risk of TB exposure (33 of 41 patients retested). None of the 35 who retested negative were offered isoniazid prophylaxis and none developed TB over a cumulative follow-up of 41 patient-years.
While much of the literature has focused on the problem of false-negative results in QFT testing of HIV-infected patients, this report cautions us about the possibility of false positives whenever we test low-prevalence populations. Unfortunately the lack of a reference standard leaves both the prognosis of positive-to-negative QFT reversion and the merits of repeat testing in HIV-infected patients unclear, particularly in those who have advanced HIV despite their lack of epidemiologic risk factors for TB.
(Gray et al. Clin Infect Dis 2012;54:e20-e23.)
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PFC Exposure and Childhood Antibody Response: A Concerning Association
Reviewed by Christian B. Ramers, MD, MPH
Perfluorinated compounds (PFCs) are widely used in manufacturing, industrial, food packaging, and textile applications. Recent studies in rodents have shown that the humoral immune system is highly sensitive to perfluorooctanoic acid (PFOA) at comparable levels of exposure in humans. A study in the Jan. 25 issue of The Journal of the American Medical Association investigates this concerning relationship in children.
Investigators conducted a prospective cohort study in the Faroe Islands, enrolling 656 consecutive singleton births from 1999 to 2001 and following 587 of these children through 2008. PFC exposure was determined both pre-natally (maternal serum levels at 32 weeks gestation) and post-natally at 5 years of age. All children received immunizations against tetanus, diphtheria, polio, pertussis, and Haemophilus influenza type B at 3, 5, and 12 months and at 5 years. The primary study endpoints were serum antibody concentrations at age 5 (both pre- and post-vaccination) and 7 years.
Exposure to PFCs—particularly PFOA and perfluorooctane sulfonic acid (PFOS)—was significantly negatively correlated with serum antibody response. A two-fold increase in pre-natal exposure to PFOS was associated with a 39 percent lower anti-diphtheria antibody titer (95 percent CI 17-55 percent decrease) at the 5-year pre-booster visit. Similarly, a two-fold increase in post-natal (5 year old) PFOA exposure was associated with a 36 percent lower anti-tetanus antibody titer (95 percent CI 14-52 percent) and a 25 percent lower anti-diphtheria antibody titer at 7 years (95 percent CI 2-43 percent). The odds ratio of anti-diphtheria antibody concentrations falling below the protective level of 0.1 IU/mL was 2.48 at 5 years (95 percent CI 1.55-3.97) for pre-natal PFOS concentrations and 3.27 at 7 years (95 percent CI 1.43-7.51) for post-natal PFOS concentrations.
If these associations are causal, the clinical implications are alarming: PFC exposure may decrease a child’s likelihood of being protected from vaccine-preventable diseases, despite receiving a full vaccine series. Although the Faroe Islands were chosen because of an expected higher level of exposure to PFCs through a diet rich in seafood, both the pre-natal and post-natal serum levels found were lower than those found in surveys of American pregnant women and children in recent studies.
(Grandjean et al. JAMA 2012;307(4): 391-397.)
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For a review of other recent research in the infectious diseases literature, see “In the Literature,” by Stanley Deresinski, MD, in each issue of Clinical Infectious Diseases:
- Malaria Prevention With Ivermectin
- Paracoccidioidomycosis in Brazil
- Progressive Multifocal Leukoencephalopathy; Variable Presentations and Clinical Course: AIDS, Organ Transplantation, Natalizumab
- Periscapular Abscess