This is an electronic update for members and friends of the American Association of Public Health Physicians (AAPHP). We issue this from time to time, whenever several items of interest come to our attention.

Please send items of interest for the E-News -- and any other feedback -- to E-News editor Dave Cundiff, MD, MPH. Thanks!

CONTENTS:

1) Avian Influenza Update:

The big news this week mostly came from China, with avian outbreaks in several areas and with three cases believed to represent bird-to-human transmission of highly pathogenic avian influenza H5N1 (HPAI H5N1). That doesn't represent any ACTUAL change in the virus' genetics or epidemiology. China is thought to have special POTENTIAL for future viral mutations, though, because of China's dense human and animal populations.

Avian influenza control in China involves bird vaccination, bird culling, and separation of potentially infected animals from flocks believed to be uninfected. Surveillance is a challenge, though. Animal and human disease information isn't consistently reported to regional and national public health authorities. Chinese health officials are trying to improve surveillance and response systems.

In Thailand, the national authorities are praising the central province of Lopburi for excellent public-private cooperation in avian influenza control. Local residents voluntarily suspended cockfighting matches and cooperated with agricultural quarantines. These measures reportedly controlled a recent avian influenza outbreak very rapidly.

Intense global surveillance and intense media interest assure great publicity for any unknown phenomenon that can be connected in any way to any strain of "avian flu". In a large and diverse world, that means a lot of news stories. When first published, they look dramatic and ominous. With perspective, most of the "bird flu" news comes to appear less surprising and more technical.

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Scientists remain uncertain about prospects for a pandemic variant of HPAI H5N1. This week's issue of Science magazine has an article, "Avian Influenza: Pandemic Skeptics Warn Against Crying Wolf", by Dennis Normile. Everyone quoted agrees that pandemic preparations are crucial and that an effective H5N1 vaccine is needed quickly, but no H5 virus has ever caused a known human pandemic and there is a vigorous debate about how likely an H5N1 pandemic might be. Immunologist/virologist Paul Offit, from the University of Pennsylvania, says scientists should tell the public "not that we're going to protect you from the bird flu pandemic, but that we're going to be protecting you from a pandemic which may be 20 years from now."

AAPHP Webmaster Kim Buttery, MD, MPH says the "Pandemic Skeptics" article "should be required reading for any public health physician who may be asked questions by elected officials or other MD's." Hardcopy may be found at Science 2005 Nov 18;310(5751):1112-1113. Paid subscription is required to view the full article on the Web at http://www.sciencemag.org/cgi/content/summary/310/5751/1112 . E-News readers without other access to Science magazine may request individual copies of the "Pandemic Skeptics" article as a PDF file (one megabyte) from cundiff@reachone.com .

The British journal The Lancet notes a global consensus for preparedness, then editorializes, " Even before a pandemic emerges, panic is a danger. The recent growth in momentum for action against avian influenza has been flanked by a rise in anxiety about the pandemic risk. These fears are perpetuated by politicians' misplaced instincts to withhold information instead of talking openly about the disease. And, worryingly, experience shows that widespread fear can lead to social and economic consequences as serious as the disease itself."

The Lancet editorialist notes that it is particularly tempting for leaders to withhold information about scant supplies of anti-influenza drugs -- but comments that full information must still be shared, partly because all of the most effective measures are education-based rather than drug-based anyway. Free registration is required to view the full editorial at http://www.thelancet.com/journals/lancet/article/PIIS0140673605677069/fulltext .

2) Teaching Health Departments - Request for Input:

AAPHP past president Joel L. Nitzkin, MD, MPH, DPA sent this item:

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AAPHP member Hugh S. Fulmer, MD, MPH has identified what seems to be a promising opportunity to recreate the "Teaching Health Department" concept in a viable and durable manner. AAPHP Vice President Kevin M. Sherin, MD, MPH and I are exploring whether AAPHP should become involved in this process, and how.

Dr. Fulmer proposes the establishment of a free-standing one-year Preventive Medicine practicum residency program at multiple sites, both domestic and international -- to train both physicians and other categories of health and social service professionals in community organization, applied epidemiology, and other skills as being presented in our project on "Improving Preventive Services in Healthcare Settings."

Key to this proposal is the concept that some local and state health departments would become "Teaching Health Departments." Teaching health departments, as envisioned, would become sites for the preventive medicine residency practicum year. Access to well-qualified mentors would be a prerequisite for Health Department participation. Academic partnerships would be a strong "plus".

According to Dr. Fulmer, interest in such a program seems strong from Massachusetts organizations and private foundations. Other potential funding sources are being explored. A qualified "go" signal, inviting further exploration of this issue, has been secured from the Residency Review Committee (RRC).

If time permits, I hope we can discuss this concept briefly at our Sunday morning business meeting in Philadelphia on December 11, 2005. In order to structure presentation of this topic, and to identify those who may want to participate, please respond to the following questions by E-mail, preferably by close of business, Friday, December 2:

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Please send comments to AAPHP's Secretary at cundiff@reachone.com . Comments will be compiled before the 2005-12-11 meeting. Thanks for your feedback!

3) CDLS Registration Form Available - Register Soon!

AAPHP and the American Public Health Association (APHA) have confirmed pre-registration procedures for the AMA's Core Disaster Life Support program, to be held at the APHA Annual Meeting in Philadelphia, Pennsylvania, on Sunday 2005-12-11.

This course will be offered in the International Ballroom Salon I at the Philadelphia Downtown Marriott Hotel, 1201 Market Street, on Sunday from 2:30 to 6:30 pm. Four hours of Category I CME credit are included without charge.

To attend the CDLS course AND other APHA Annual Meeting sessions, we encourage you to register on-site for the APHA Annual Meeting. On-Site and One-Day registration fees are detailed at http://www.apha.org/meetings/reg_fees.htm . The Annual Meeting badge will admit you to the CDLS course without charge.

The APHA Annual Meeting badge will also give you access to the Opening General Session (featuring public health physicians recounting lessons from Hurricane Katrina) and to other APHA events noted at http://apha.confex.com/apha/133am/techprogram/ .

AAPHP members may take the CDLS course without charge, whether or not they are also registered for the APHA Annual Meeting, if they pre-register for CDLS by 2005-12-04.

Everyone attending the CDLS Course is strongly encouraged to pre-register by 2005-12-04, in order to assure enough seats and materials for all. The registration form is suitable for both APHA Annual Meeting attenders and AAPHP members. Registration forms are available in either PDF or Microsoft Word format at http://www.aaphp.org/Meetings/fall05apha.htm . If you have trouble downloading or sending the form, please contact the AAPHP Secretary, cundiff@reachone.com .

Please remember also the AAPHP General Membership Business Meeting in Philadelphia, from 10:30 to 11:30 am on Sunday 2005-12-11, at the Philadelphia Marriott Downtown Hotel, Room 301. The business agenda will be published in E-News and on the Web before the meeting.

4) Vaccine Distribution Discussion on Public Health Blog:

Shortly after the last E-News was published, AAPHP member Ashwani K. Garg, MD E-mailed the editor, "What can AAPHP do to take vaccine distribution out of the hands of commercial pharmacies and into the hands of physicians, hospitals, nursing homes, and especially, public health departments that can assure that the right people will receive the right vaccine at the right time?"

Dr. Garg used the "Reply to All" button for his reply. We had thought that "Reply to All" would not send E-mail to the whole list. We were wrong. All E-News subscribers got that E-mail -- and one more -- in what began to be a vigorous discussion about U.S. vaccine distribution policies.

Since many of you didn't expect to get anything from this listserve except the E-News, we changed the listserve settings quickly. (See item on "spam control" below.) We also realized the need for an electronic discussion forum that could host important policy discussions like this one.

AAPHP Webmaster Kim Buttery, MD, MPH also operates a "Public Health Blog" at Virginia Commonwealth University. Dr. Buttery posted a version of Dr. Garg's question on his Public Health Blog at 12:16 pm EST on Tuesday 2005-11-15. Other comments are already attached to this entry.

The permanent address for this month's Public Health Blog page is http://blog.vcu.edu/cbuttery/archives/2005_11.html . Please page down to the entry you want. Everything is arranged chronologically; several other stories were posted on 2005-11-15 in addition to the "Where Should I Get My Flu Vaccine?" story.

Another way to get to Dr. Buttery's blog is via the "Public Health Blog" tab at http://www.aaphp.org .

We welcome dialogue, in the Public Health Blog and elsewhere. We'll summarize that dialogue from time to time in the E-News.

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In what some would consider to be a related topic, the 2005-11-19 entry in the Public Health Blog asks, "Shouldn't we ban ALL prescription drug advertising?" Check out http://www.thelancet.com/journals/lancet/article/PIIS0140673605677124/fulltext (free registration required) and visit http://blog.vcu.edu/cbuttery/archives/2005_11.html to add your comments on pharmaceutical advertising policy.

5) New "Spam Control" for the E-News Listserve:

When some members began a discussion of vaccine policy on the listserve, we were delighted by the topic and by the thoughtful contributions. We were also dismayed because we had promised all of you that we would control unsolicited E-mail on this listserve.

Of the 300-plus physicians and medical students on this listserve, nobody tried to "unsubscribe" due to the extra E-mails. That shows your interest in the topic, and your faith in the value of AAPHP's E-News. Thank you.

This week we tightened procedures so that only a few people can post information on the E-News listserve, and even those few will need a password. We hope that this new process will assure that you don't receive non-urgent mail other than the E-News itself. Thanks for your patience as we learn the new system.

We're willing to consider establishing a different listserve, separate from E-News, that would be suitable for serious discussions among Public Health Physicians. Enrollment in the discussion listserve would require a separate request, from physicians who are willing to receive an unpredictable amount of E-mail from other public health physicians. If you would like to see AAPHP start such a listserve, or if you would like to help AAPHP establish and manage one, please E-mail the editor with your ideas.

We also welcome -- always! -- your feedback to the editor. We'll try to publish a variety of points of view in the E-News, in order to keep the E-News fresh, informative, and useful.

6) Acinetobacter Infections Seen in Iraq War Casualties:

The current issue of Infectious Disease News summarizes two presentations from the October 2005 meeting of the Infectious Diseases Society of America, about severely wounded U.S. soldiers returning from Iraq with Acinetobacter baumannii infections.

Acinetobacter was a common infection among wounded soldiers in Vietnam. The big difference is that most isolates from the Iraq conflict are resistant to multiple antibiotics. Carbapenem still works fairly reliably (93% of isolates are carbapenem-sensitive), but most strains are sensitive only to one or two classes of antibiotics.

The infection has been seen mostly in soldiers, but there have been some cases in wounded civilians as well. Initially, the common factor was that all patients with resistant Acinetobacter had received major operations at field hospitals in Iraq. Subsequently, cases have been seen in persons treated at other military facilities.

Acinetobacter is commonly found in soil. Culture of 31 soil samples in Iraq didn't yield Acinetobacter . Military physicians are attempting to improve isolation procedures, and to upgrade hand-hygiene equipment and training, in all affected facilities.

Free registration is required to view the full article at http://www.infectiousdiseasenews.com/200511/frameset.asp?article=soldiers.asp .

7) Report from AMA Interim Meeting :

AAPHP's President and AMA Delegate Arvind K. Goyal, MD, MPH sent this report from the American Medical Association (AMA) House of Delegates meeting, held in Dallas November 4-8, 2005:

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  1. AAPHP's Resolution, Public Health Lessons from Hurricane Katrina, was renamed "Emergency Preparedness", strengthened with several friendly amendments, and adopted after extensive debate at the Reference Committee and on the floor of the House. As a result, the AMA will call for each state and local public health jurisdiction to develop and periodically update, with public and professional input, a comprehensive Public Health Disaster Plan, specific to their locations. The plan will be deposited timely with appropriate Federal Agencies. The AMA will also advocate for various Disaster Life Support Courses, validation of Medical License from other states to work in a distressed jurisdiction in case of a federal emergency, and support national legislation giving automatic medical liability immunity to qualified physician volunteers in the case of a declared national disaster or federal emergency.
  2. AAPHP's Resolution, COBRA Insurance Becoming Unaffordable, was not adopted due to lack of supporting wvidence that COBRA Premiums for unemployed workers were indeed substantially higher than the sum of that charged a working individual + that paid by the employer on that individual's behalf. That resolution could be re-introduced at a future AMA meeting with additional evidence.
  3. Another resolution asking AMA to work to ensure national legislation to ban smoking in food establishments was expanded to actively pursue and support national, state and local legislation and regulations banning smoking in all workplaces. The AMA House also adopted an amendment by the AAPHP delegate on the floor of the House asking AMA to ensure that such federal legislation does not prohibit or weaken existing more strict state or local regulations.
  4. The AMA House adopted a Council report on expanding health insurance coverage to the insured, but amended it to "place a high priority on expanding health insurance coverage for all" Americans including the underinsured.
  5. A resolution requiring that all Americans have, at minimum, catastrophic and preventive health care coverage was referred to the AMA Board.
  6. In another action, the House asked Council on Ethical and Judicial Affairs to clearly establish boundaries of ethical practice for physicians participating in the interrogation of prisoners and detainees.
    The AAPHP Delegate was appointed by the Speakers to serve as a member of the Reference Committee K, which heard resolutions on advocacy in the private sector.
  7. The AAPHP actively participated in the deliberations of the Specialty and Service Societies (SSS) and the Section Council on Preventive Medicine (SCPM) at the AMA. The AAPHP Delegate currently serves as the elected chair of the SCPM.

    Dr, Douglas Mack and I are honored to represent the AAPHP as your AMA Alternate Delegate and Delegate respectively. Please feel free to direct any questions about this report, other suggestions or ideas for future resolutions to any of us.

    Respectfully submitted,
    ARVIND K. GOYAL, MD, MPH
    AAPHP Delegate to the AMA

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A report of AAPHP's work at the AMA, including the Disparities Commission and the Advisory Committee on CPT coding, is planned for the next AAPHP Bulletin . We expect to mail the printed Bulletin to all AAPHP members at the end of November.

8) Member Update:

Thanks to AAPHP members Eleanor Abella, MD; John M. Caroline, DO; Gary Goldbaum, MD, MPH; Douglas Holt, MD; and Iraj Lou, MD, for joining or renewing AAPHP membership since the last E-News issue.

AAPHP's 2006 membership form is available at http://www.aaphp.org/Membership/2006MembershipForm.pdf . Medical students and residents (in any specialty) may join AAPHP without charge for 2006 and 2007. Other physicians may join or renew at the 2005 dues level until 2005-12-15.

9) Acknowledgements:

In addition to sources cited above, AAPHP thanks the ProMED-Mail service of the International Society for Infectious Diseases ( http://www.promedmail.org ) for much of this week's material on avian influenza. Thanks also to AAPHP Webmaster Kim Buttery, MD, MPH; AAPHP members Ashwani K. Garg, MD and Phillip C. Gioia, MD, MPH; Infectious Diseases physician Michael J. Muszynski, MD; and AAPHP Vice President Kevin M. Sherin, MD, MPH, for sending material included or summarized in this issue.

Thanks to Georges C. Benjamin, MD, APHA Executive Director; to J. Alan Baker, APHA Chief of Staff; to James J. James, MD, DrPH, MHA, Director of the AMA's Center for Public Health Preparedness and Disaster Response; and to AAPHP President Arvind K. Goyal, MD, MPH, for arranging the CDLS Course for 2005-12-11.

Special thanks to AAPHP member Virginia M. Dato, MD, MPH. As AAPHP Secretary in the late 1990's, she was the founding editor of the E-News. She serves as a technical and professional consultant to the current editor, generously sharing her time and expertise "behind the scenes". AAPHP might not have an E-News to offer if it were not for Dr. Dato's foresight and skill.

Finally, thanks to the physicians who join AAPHP -- and particularly to those who join both AAPHP and AMA. Because many AAPHP members also join the AMA, Public Health still has a strong, clear voice of its own in the AMA House of Delegates. This position gives Public Health physicians a voice in other medical circles, as well as in the AMA itself. AAPHP membership information is at http://www.aaphp.org . AMA membership information is at http://www.ama-assn.org/ama/pub/category/12896.html .

Dave Cundiff, MD, MPH ( cundiff@reachone.com )

AAPHP Secretary and E-News Editor

************ About AAPHP E-News ************

This message is an electronic update from the American Association of Public Health Physicians (AAPHP) to public health physicians.
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