ACIP Recommendations for Pneumococcal Vaccination

The Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) has updated its recommendations on pneumococcal vaccination for cochlear implant candidates and recipients. The recommendations are available online atwww.cdc.gov/mmr/preview/mmwrhtml/mm5231a5.htm.

In October 2002, the CDC recommended that all persons with cochlear implants receive age-appropriate pneumococcal vaccination with 7-valent pneumococcal conjugate vaccine (PCV7), 23-valent pneumococcal polysaccharide vaccine (PPV23), or both, according to the ACIP schedules for persons at high risk. The CDC issued these recommendations on the basis of preliminary data suggesting an increased risk for pneumococcal meningitis in persons with cochlear implants. Findings of a recent investigation by the CDC, the U.S. Food and Drug Adminisration, and state health departments support this recommendation. Children younger than six years with a cochlear implant have a substantially greater risk for having pneumococcal meningitis, compared with children in the general population of the same age. Some children who are candidates for cochlear implants have pre-existing anatomic factors that might contribute to an increased risk for meningitis; however, the recent study was not designed to assess this association.

Because the rate for pneumococcal meningitis is higher in children with cochlear implants, and because Streptococcus pneumoniae is the most common pathogen causing bacterial meningitis in cochlear implant recipients of all ages with meningitis of known etiology, the ACIP recommends the following for persons who have or are scheduled to receive a cochlear implant:

• Children younger than 24 months with cochlear implants should receive PCV7, as is universally recommended; children with a lapse in vaccination should be vaccinated according to the catch-up schedule issued after the PCV7 shortage resolved (available online at www.cdc.gov/mmwr/preview/mmwrhtml/mm5219a6.htm).

• Children 24 to 59 months of age with cochlear implants who have not received PCV7 should be vaccinated according to the high-risk schedule (available online at www.cdc.gov/mmwr/preview/mmwrhtml/rr4909a1.htm#tab8); children with a lapse in vaccination should be vaccinated according to the catch-up schedule (above) for persons at high risk issued after the PCV7 shortage resolved. Children who have completed the PCV7 series should receive PPV23 more than two months after vaccination with PCV7.

• Persons five to 64 years of age with cochlear implants should receive PPV23 according to the schedule used for persons with chronic illnesses; a single dose is indicated.

• Persons planning to receive a cochlear implant should be up-to-date on age-appropriate pneumococcal vaccination more than two weeks before surgery, if possible.

Physicians should review vaccination records of their patients who are cochlear implant recipients or candidates to ensure they have received pneumococcal vaccinations based on the age-appropriate schedules for persons at high risk. In addition, all cases of meningitis should be reported to state health departments according to state requirements. Because information about S. pneumoniae serotypes causing pneumococcal meningitis in persons with cochlear implants is limited, physicians are encouraged to send isolates to their state health department, which can forward isolates to the CDC, where serotyping can be performed to determine whether the type is included in the vaccines.

AAP Guidelines on Childhood Obesity

The American Academy of Pediatrics (AAP) has released a new policy statement on childhood obesity. “Prevention of Pediatric Overweight and Obesity” is available online atwww.aap.org/policy/s100029.html.

The dramatic increase in the prevalence of childhood obesity and its resultant comorbidities are associated with significant health and financial burdens, warranting strong and comprehensive prevention efforts. A primary diagnostic tool suggested by the AAP is the body mass index (BMI), which is widely used to define overweight and obesity (see editor's note below). Significant changes in a child's BMI should be recognized and addressed before the child becomes severely overweight. The policy points out that some parents may not recognize or accept the potential risk of their child being overweight. It also notes that anticipatory guidance or treatment intervention before obesity has become severe will likely be more successful.

According to the AAP, the number of overweight and obese children has doubled in the last two decades. Currently, 15.3 percent of children six to 11 years of age and 15.5 percent of children 12 to 19 years of age are at or above the 95th percentile for BMI based on reference data from the 1970s.

Recommendations in the AAP policy include the following:

• Identify and track patients at risk by virtue of family history; birth weight; and socioeconomic, ethnic, cultural, or environmental factors.

• Calculate and plot BMI once a year in all children and adolescents.

• Use change in BMI to identify rate of excessive weight gain relative to linear growth.

• Encourage, support, and protect breastfeeding.

• Encourage parents and caregivers to promote healthy eating patterns.

• Routinely promote physical activity, including unstructured play.

• Recommend limitation of television and video time to a maximum of two hours per day.

The new policy advocates that physicians help parents, coaches, and others who influence youth to discuss health habits, not body build, as part of their efforts to control overweight and obesity.

editor's note: Tools for calculating BMI and updated clinical growth charts for use in office practice are available at no charge online atwww.cdc.gov/growthcharts. A free BMI calculator for handheld computers using the Palm operating system is available online at hin.nhlbi.nih.gov/bmi_palm.htm.—mark h. ebell, m.d., m.s.

AHRQ Checklists for Men and Women

The Agency for Healthcare Research and Quality (AHRQ) has developed checklists for men and women to use during an examination by their family physician. The checklist for women is available online atwww.ahrq.gov/ppip/healthywom.htm, and the checklist for men is atwww.ahrq.gov/ppip/healthymen.htm.

The checklists were developed using research and recommendations from the U.S. Preventive Services Task Force. They give recommendations about screening tests, the use of medications to prevent disease, and tips for good health, such as smoking cessation and physical activity. English and Spanish versions are available.

FDA Approval

• Levitra. The U.S. Food and Drug Administration has approved vardenafil (Levitra) for the treatment of erectile dysfunction. Vardenafil helps increase blood flow to the penis and may help men with erectile dysfunction get and keep an erection satisfactory for sexual activity.

Vardenafil may be used once a day. Men taking nitrate drugs or alpha blockers should not use vardenafil. According to the manufacturer, the most commonly reported side effects are headache, flushing, and stuffy or runny nose. Vardenafil also can cause priapism and vision changes, such as seeing a blue tinge to objects.

Vardenafil is available in doses of 2.5 mg, 5 mg, 10 mg, and 20 mg. For most men, the recommended starting dose is 10 mg. Doses should be taken at least 24 hours apart, and one hour before sexual activity. Sexual stimulation is needed for an erection to occur.