Please send items of interest for the E-News -- and any other feedback -- to E-News editor Dave Cundiff, MD, MPH <cundiff@reachone.com>. Thanks!
CONTENTS:
1) Influenza Update
2) AAPHP to Meet at APHA
3) Will a Veterinarian Shortage Endanger Public Health?
4) Public Health Blog Added to AAPHP Web Page
5) Managing Patients Infected with Both HIV and HCV
6) Notes in a Bottle
7) Member Update
8) Acknowledgements
1) Influenza Update:
Highly pathogenic avian influenza H5N1 (HPAI H5N1) continues to be found -- in birds! -- in more and more places. Outside of southeast Asia, though, there have been few if any reports of transmission to humans. So far, this virus still shows no sign of the communicability required to generate a pandemic.
Public health authorities in some affected countries are citing HPAI H5N1 as a reason for special emphasis on this year's influenza vaccine programs. Sometimes they cite the belief -- not supported by evidence -- that regular influenza vaccine protects individuals against H5N1 disease. A more accurate justification would be based on a public health analysis:
If fewer people are infected with human influenza strains as a result of a vaccine campaign, then it is less likely that anyone will be infected with both human and avian influenza strains at the same time. If there is less co-infection, there should be fewer opportunities for genetic mixing between HPAI H5N1 and the more transmissible human influenza strains. That might lessen the danger that HPAI H5N1 will transform into a pandemic strain in the future.
Additional reports of avian influenza (which may or may not be HPAI H5N1) are coming from many European and Asian countries. Many of the new reports are based on observation and testing of imported birds, in quarantine facilities, or testing of smuggled birds that have been captured by Customs enforcement. The bird trade is extensive, and much of it is underground. Regardless of human health effects, avian influenza -- in its present forms -- can do a lot of damage to poultry farmers and consumers wherever it spreads.
2) AAPHP To Meet at APHA:
The AAPHP Board has decided on meeting dates at the Annual Meeting of the American Public Health Association in Philadelphia. Our Business Meeting is currently set for SUNDAY, DECEMBER 11, 2005 and our Educational Sessions are currently set for SUNDAY OR MONDAY, DECEMBER 11 OR 12, 2005.
We will confirm specific times and locations as soon as possible. Setting up these sessions has been delayed by negotiations with other organizations -- but we believe this cooperation will result in a better experience for AAPHP members.
If you come to Philadelphia, we hope you'll also spend time at the APHA sessions. APHA meeting registration is available on line until 2005-11-04 at http://www.apha.org/meetings .
3) Will a Veterinarian Shortage Endanger Public Health?
Jennifer Bails' 2005-09-25 article, "Veterinary Shortage Endangers Security", in the Pittsburgh Tribune-Review, reminds us that Public Health veterinarians and large animal (or other agricultural) veterinarians are a mainstay of public health protection in many areas -- not just avian flu. Facing large educational debts and wanting family time, many graduating veterinarians are establishing pet care practices, rejecting the less predictable hours and adverse working conditions that often characterize a large-animal or public-health veterinary practice.
The full report is available at http://www.pittsburghlive.com/x/tribune-review/trib/regional/s_377627.html .
We asked experts for comment. Everyone agrees that public health veterinarians are important, but the E-News editor is still trying to find a quantitative analysis of veterinary public health workforce trends. We'll report significant material as we get it.
4) Public Health Blog Added to AAPHP Web Page:
AAPHP Webmaster Kim Buttery, MD, MPH has kindly linked our Web page to the Public Health Blog that he operates as a faculty member at Virginia Commonwealth University.
Dr. Buttery posts a variety of public health topics, with links to the original sources. Topics are arranged chronologically, with more recently posted topics at the top. Participants can leave comments and engage in discussions.
For access, go to http://www.aaphp.org . At the left side of the page, click "Public Health Blog".
5) Managing Patients Infected with Both HIV and HCV:
The E-News editor attended a talk on co-infection by Human Immunodeficiency Virus (HIV) and Hepatitis C Virus (HCV) by Margaret Shuhart, MD, Associate Professor of Medicine at the University of Washington in Seattle, on October 6, 2005. Highlights of Dr. Shuhart's talk:
HIV facilitates Hepatitis C's transmission (at least perinatally) and pathogenesis. Coinfection is common -- up to 85% of U.S. drug users with HIV also have HCV. Since the introduction of highly active anti-retroviral therapy (HAART), liver-related mortality has represented 50% of the total deaths in HIV patients in several U.S. centers.
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HIV treatments can be hepatotoxic. The most feared hepatic complication from HAART is the mitochondrial toxicity of nucleoside reverse transcriptase inhibitors (NRTI's) -- especially d4T, ddI, and ddC. Other hepatotoxicity is seen in the form of varying degrees of liver elevation.
HAART seems to INCREASE liver enzymes, perhaps as a revitalized immune system attacks infected liver cells. Based on observational studies, though, HAART appears to LOWER the rates of cirrhosis. Because these are observational studies, their conclusions are limited by selection bias, survivorship bias, and competing risks.
Even with severe liver enzyme abnormalities, many authorities report that they are able to continue HAART without compromising outcomes. However, the risk of continuing HAART in the setting of severe liver enzyme abnormalities has not been studied prospectively. Consultation with an HIV-experienced clinician or hepatologist may be needed.
HCV treatments can complicate HIV and its treatment as well. Ribavirin may increase the toxicity of ddI by enhancing its metabolism. Ribavirin may also increase the bone marrow toxicity of zidovudine (ZDV).
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Can we treat all co-infected patients for their HCV infection? Not really. HCV treatment is useful in carefully selected outpatients, but statistically it can only make a modest dent in the problems of co-infection. There are at least four factors that inhibit the initiation and/or success of HCV treatment in patients who are also infected with HIV.
First, most patients with HIV/HCV co-infection aren't eligible for HCV treatment. One study showed that among non-incarcerated outpatients with HIV/HCV co-infection, only 28% were eligible for treatment by standard criteria.
Second, refusal and non-adherence are common. In the study mentioned above, some of the 28% refused treatment. Others stopped treatment after initiation.
Third, HCV treatment doesn't always work at all -- especially with Genotype 1, which is the most common in the USA. Expect that even with meticulous adherence, fewer than half of co-infected patients in the USA will completely clear their HCV infection.
Fourth, even when HCV treatment works, the response to HCV treatment may be slower in HIV/HCV co-infected patients. They may require longer treatment intervals before response can be assessed and before treatment can be deemed complete. Clinicians who adhere rigidly to the regimens recommended for other HCV patients may not achieve the best possible outcomes when their HCV patients are also infected with HIV.
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Guidelines from the American Association for the Study of Liver Diseases (AASLD) recommend that HCV treatment is appropriate in patients with periportal fibrosis or with higher-stage liver damage. AASLD reports that there are no data to support a CD4 threshold for withholding HCV treatment. They also suggest a 48-week course of HCV treatment for co-infected patients.
Dr. Shuhart notes that HCV viral loads help predict treatment response, and are an important part of monitoring response to treatment. She tests HCV viral load on all co-infected patients. Before starting HCV treatment in co-infected patients, she recommends substituting another NRTI for ddI, and she considers modification of ZDV treatment.
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Liver transplantation has been tried only in a few carefully selected patients. These patients' baseline prognosis may have been much better than that of co-infected patients as a whole. Transplantation does not appear to be associated with HIV progression, or with increased rates of opportunistic infections.
Post-transplant HCV recurrence is universal. Post-transplant HCV severity, in the selected group of co-infected patients who have been transplanted so far, has appeared to be no greater than that of HIV-negative patients. (Newer data, with longer follow-up, are casting preliminary doubts on this conclusion.) Because of the complex drug interactions between post-transplant drugs and HIV drugs, clinicians should monitor drug levels very carefully in post-transplant patients.
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(Editor's Note: Thanks to Dr. Shuhart for a clear and accessible presentation on the clinical management of co-infected patients. Those at greatest risk for co-infection are unlikely to present for health care until after co-infection has occurred. Therefore, the prevention of HIV/HCV co-infection is primarily a public health challenge, not a healthcare system challenge. Our Correctional Health members may have some of the best educational opportunities, especially in local jails. Syringe exchange programs appear likely to help as well.)
6) Notes in a Bottle:
AAPHP Member Don MacCorquodale, MD, MPH recently posted two issues of "Notes Washed Up In A Bottle". Each issue reports on several public health issues.
The 2005-10-18 issue surveys an article on childhood obesity from Nutrition Journal ; cites research that suggests other sexually transmitted infections may interact with HPV to promote cervical cancer; and reports on 2004-2005 infant mortality rates by U.S. state. This issue is posted at http://www.aaphp.org/bottle/2005/Oct18.htm .
Today's issue notes that children say "ow" when receiving injections for immunization. (One usually dry commentator wrote, "Well there's a surprise.") A recent BMJ article reviewed 31 "high quality" studies refuting the alleged link between MMR vaccine and disabling diseases. Two recent studies of reproductive outcomes and DDT/DDE exposure have shown basically inconclusive results; "Notes in a Bottle" summarizes these two studies in detail. This issue is posted at http://www.aaphp.org/bottle/2005/Oct26.htm .
Thanks to Dr. MacCorquodale for his contributions!
7) Member Update:
Thanks to Steven R. Jarrett, MD; David R. Johnson, MD, MS; and Stan Reedy, MD, MPH, for joining and/or renewing AAPHP membership since the last E-News.
8) Acknowledgements:
Thanks to the International Society for Infectious Diseases and to their update service, ProMED-Mail, for much of the material used to prepare this issue's "Influenza Update". Readers who want more detail on international infectious disease issues, and who want these details faster, can subscribe to ProMED-Mail at http://www.promedmail.org .
Thanks also to Margaret Shuhart, MD and the Department of Medicine, University of Washington; to AAPHP member Don MacCorquodale, MD, MSPH; and to AAPHP Webmaster Kim Buttery, MD, MPH. They supplied the E-News with helpful information; reviewed and commented on preliminary drafts; and provided technical support for E-News production.
And thanks to you, AAPHP members and E-News readers, whose interest and support makes the E-News worthwhile!
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Dave Cundiff, MD, MPH ( cundiff@reachone.com ) AAPHP Secretary and E-News Editor
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