A Publication of the
Program on Prevention
In Education & Practice
June
2002 - Volume 1, Number 12
The Smallpox Dilemma
Following the events of Sept. 11, 2001 and the subsequent anthrax attacks, public health officials have been concerned about the possibility of a bioterrorist smallpox attack. The April 25, 2002 issue of the New England Journal of Medicine (www.nejm.org) included a series of articles about smallpox, including a review of the diagnosis and management of smallpox, 2 reports of studies of the effectiveness of diluted vaccine, and a debate about smallpox vaccination policy. Smallpox, with a case-fatality rate of 30%, would likely spread quickly throughout the US, if it were to be introduced.
Routine vaccination against smallpox was discontinued in 1972, because the risk for serious adverse effects from the vaccine was higher than the risk of disease. While the 2 studies of effectiveness of diluted vaccine found that, even at a 1:10 dilution, the current vaccine appears to be effective, it is also associated with mild to serious side effects, ranging from rash and fever to eczema vaccinatum (seen in persons with eczema) to encephalitis and, rarely, even death. Alex Kemper and Gary Freed, former members of the UNC Dept. of Pediatrics, recently published a report in Effective Clinical Practice (Eff Clin Pract. 2002;3:84-90; http://www.acponline.org/journals/ecp/) in which they made a "back-of-the-envelope" estimation that a strategy of vaccinating people aged 1 to 65 would result in approximately 4600 serious adverse events and 285 deaths.
Given the complexity of this public policy decision about smallpox vaccination, both the CDC and the Institute of Medicine have held public discussions to explore the issues and allow input from a variety of experts and lay citizens on this topic. Dr. Stuart Bondurant, UNC faculty member and former Dean of the School of Medicine, chaired an IOM forum on the scientific basis for smallpox vaccination policy options on Saturday, June 16, 2002. The CDC hosted a series of 4 public sessions around the country June 6-11. Results of these discussions are not yet available, but they will likely be influential in setting smallpox vaccination policy in the coming months.
Neuroblastoma-
To Screening or not to Screen? 
Two recent articles in the New England Journal of Medicine show that screening isn't always the best medicine. Neuroblastoma is the second most common tumor found in children, affecting 1 in 7,000 children. Because it can be a fatal condition, screening all infants for neuroblastoma with a simple urine test has been considered. The two NEJM studies examined neuroblastoma screening programs- one in Germany and one in Quebec. The goal of both studies was to determine whether screening for neuroblastoma in infancy leads to decreased mortality from this disease.
In the Quebec study,*350,150 children were screened; 43 had positive screening tests. At the time of follow-up (72-132 months later), all 43 of these children were still alive. However, 18 children, 17 of whom had negative screening results, died of neuroblastoma (one screening test was mistakenly read as negative but was positive on re-testing). Mortality rates from neuroblastoma in the screened cohort were very similar to the rates in four control groups (approximately 3.5 - 5.5 per 100,000).
In the German study,** 1,475,773 children were screened with the urine test and 149 cases were detected. Of these detected cases of neuroblastoma, all but three children were alive at the time the article was published. The three children died from complications of treatment (which may have been unnecessary). However, 55 children who had negative screening results, presented with neuroblastoma. Mortality from neuroblastoma was similar in program area and in control areas.
These studies present an interesting analysis of the screening dilemma. In an attempt to eliminate some of the morbidity and mortality associated with neuroblastoma, universal screening seems intuitively sensible. However, these findings support the idea that there are different types of neuroblastoma that progress differently. There is the type that is detected easily with screening but rarely progresses and often disappears before becoming clinically relevant. The dangerous neuroblastomas that progress and kill may be difficult to detect with screening.
Because of the extreme expense of such a screening program, not to mention the unnecessary treatments and potential complications of those who screen positive (but may naturally lose the tumor later), screening is a poor method for reducing the burden of neuroblastoma. These findings should be considered by such countries as Japan where screening is mandatory.
*Woods W, Gao RN, Shuster
J, Robison L, Bernstein M, Weitzman S, Bunin G, Levy I, Brossard J, Doughtery
G, Tuchman M, Lemieux B. Screening of infants and mortality due to neuroblastoma.
NEJM. 2002;346:1041-6.
**Shilling
F, Spix C, Berthold F, Erttmann R, Fehse N, Hero B, Klein G, Sander J, Schwarz
K, Treuner J, Zorn U, Joerg M. Neuroblastoma screening at one year of age. NEJM.
2002;346:1047-53.
AAMC Committee Reviews Definition of "Underrepresented Minorities"
Faith Lawrence, MD, MPH, Preventive Medicine Chief Resident is serving on an advisory committee to reexamine the AAMC's definition of "underrepresented minorities." The original definition, written in 1970, identified four racial and ethnic groups as underrepresented in medicine: black, Mexican American, Puerto Rican and American Indian. These groups have historically encountered "inequitable barriers and constraints to access to the medical profession" and their representation in medicine was much less than their representation in the U.S. population.
Three factors have caused the committee to take a closer look at the appropriateness of the current definition. First, there have been dramatic demographic changes since the definition was originally written in 1970. Second, there has been increased interest in the elimination of racial and ethnic disparities in health care and health status. Lastly, a federal initiative mandates changes in the collection of racial and ethnic federal data. All organizations receiving federal funding must comply with these changes by 2003.
The committee has created a discussion document that includes four possible options:
Keep the current definition with four categories as is
Keep the four categories but
add other racial and ethnic groups to
Substitute a "strong
statement of diversity" for the current definition
Maintain a commitment to the
four current categories and also issue a "strong statement of diversity"
A decision will be made soon about which option to accept.
Additional information can be found at http://www.aamc.org/meded/urm/start.htm
Newsworthy
Notes 
Prevention News Around The Program...
UNC Students Take a Year Off from Medical
School to Obtain a Masters in Public Health Degree
Eleven UNC medical students will take next year to complete an MPH degree in the School of Public Health. A continuing trend is the high number of students selecting the Health Care & Prevention (HC&P) MPH option. We welcome the following UNC medical students into the HC&P Program:
Kimberly Clay
Anna Frick (former PACT Co-President)
Lori Haigler (post 4th year)
Jennifer Pender (post 4th year)l
Gabrielle Schneider
Julie Strum
Sheneika Walker
James
Winslow
2002-2003 distribution
of UNC medical students in MPH degree programs
Around Campus...
Wellness Program for Medical Students
Personal well-being or personal wellness is a timely issue for the medical profession with the LCME (Liaison Committee on Medical Education) requiring medical schools to have a wellness program to maintain accreditation, medical school deans talking about ways to implement programs, and legal suits bringing national attention to the high costs and risks of the traditional training of the overworked resident. Last year medical students Teresa Myers and Amy Webb brought a proposal to Georgette Dent, Associate Dean for Student Affairs, that resulted in the initiation of an UNC SOM Wellness Program. This program is designed to help medical students adjust to the physical, emotional and mental demands of the medical profession and to help them develop the personal behaviors necessary to become healthy role models for patients.
An interdisciplinary Wellness Committee was establish to define "wellness" for the medical student population and guide the development of the administrative office. A survey of some first and second year medical students identified stress management, nutrition, and physical fitness as main wellness concerns. Wellness Program students designed three-part workshops for all three topics. Workshops delivered information and techniques in wellness and individual health practices. Pre and post-surveys were given during the workshops and the data will be used to help refine future workshops.
The long-term vision is to have a staffed administrative Wellness Office established to facilitate the collection, creation and distribution of information related to wellness. Ongoing workshops based on student interest will also continue. Survey data will be critical to track wellness behavior patterns and beliefs over time allowing the group to adjust and tailor the program to best serve the program participants' needs.
For more information on the UNC SOM Wellness Program please contact one of the program coordinators listed below or go to the program web site at www.medschoollife.com/unc_wellness Outgoing Program Coordinators: Teresa Myers or Amy Webb Incoming Program Coordinator: Kelly Carney
Preventive Medicine
Residents Present Research Projects; Ferrell Awards and Lecture Given
The Preventive Medicine Residency Research Conference and the 6th Annual Ferrell Awards and Lecture were held on May 22nd. The day included presentations from three residents who will complete their training this summer. Faith Lawrence, MD, MPH, presented "Folic Acid to Prevent Neural Tube Defects: A Program Plan for Hispanic Families." Faith will be returning home to South Carolina in July to work in a Community Health Center in Beaufort. Kathleen McTigue, MD, MPH, presented "The National History of Obesity: Weight Change in a Large Cohort of Young US Students." Kathleen will join the faculty at the University of Pittsburgh this summer. Ramesh Krishnaraj, MD, MPH presented "Screening for Hereditary Hemochromatosis Using Serum Liver Enzymes: A Markov Decision Model Cost-Effectiveness Analysis." Ramesh will leave us to become the Medical Director of the Guilford County Health Department and a general internist in Greensboro.
Following these presentations, two awards were given. The John Atkinson Ferrell Prize for Lifetime Contribution to Preventive Medicine and Public health was given to Newton MacCormack, MD, MPH who received both his MD and MPH here at UNC. Dr. McCormack who has spent the majority of his career, both pre and post-retirement, in public service as the state epidemiologist. He was given this award for his lifetime commitment to public health and medicine.
The John Atkinson Ferrell Prize for Outstanding Contribution to Preventive Medicine and Public Health was awarded to Ward Cates, MD, MPH. Dr. Cates currently serves as the President and CEO of Family Health Institute after spending many years at the CDC. He has been honored with many awards including a 1998 election to the Institute of Medicine.
Who Becomes Obese? How Can We Prevent
It?
Americans are getting heavier. From 1960 to 1999, the prevalence of excess weight increased from 44% to 61% and the prevalence of obesity doubled from 13% to 27%. Obesity is a major public health concern because obesity has been linked to increased mortality and morbidity from illnesses such as hypertension, diabetes, sleep apnea, certain cancers and depression.
Preventive Medicine Resident Kathleen McTigue, MD, MPH recently published a widely-publicized study in the Annals of Internal Medicine that looked at weight changes in a cohort of 9179 people born between 1957 and 1964. For each person, height and weight were measured at twelve points between 1981 and 1998. Using these measurements to determine BMI, researchers were able to determine at what age people became obese. They were also able to determine whether sex, ethnic background and year of birth was related to their weight change patterns.
The study found that obesity tends to start in early adulthood with 26% of men and 28% of women aged 35 to 37 years being considered obese. Among women, black women became obese earliest, followed by Hispanic and then white women. Hispanic men became obese earliest among men.
Figure 4. Observed obesity at age 35 to 37 years in relationship to baseline body mass index (BMI) at age 20 to 22 years. (http://www.annals.org/issues/v136n12/full/200206180-00006.html)
Because of the use of longitudinal data in this study, high risk individuals could be determined as they entered adulthood. This is based on weight gain patterns throughout childhood and young adulthood. In all racial and ethnic groups, 20-22 year olds who were mildly or moderately overweight were substantially more often obese by age 35-37. Results of this study indicate that prevention strategies should target young adults before they develop habits that can lead to obesity. We might also wish to develop special prevention strategies to focus on high risk ethnic groups.
Dr. McTigue has received a great deal of press about this study, both here in the states and internationally. Several media outlets, including USA Today, Reuter's and Reuter's Health, and the local ABC affiliate channel 11 picked up the story. In addition, the Reuter's version was featured on the websites of MSNBC, Washington Post, United Press International, Hindustan times.com (in India), and News.Com.AU (in Australia). Dr. McTigue did this work as a Robert Wood Johnson Clinical Scholar and a Preventive Medicine Resident.
McTigue K, Garrett J, Popkin B. The natural history of the development of obesity in a cohort of young US adults between 1981 and 1998. Ann Intern Med. 2002;136:857-864.
Aspirin Chemoprevention
A recent Time magazine article, boasting the benefits of taking a daily aspirin to prevent heart disease, mentioned work from UNC. Dr. Mike Pignone's risk calculator website was noted as a site where individual patients (or physicians) can go to calculate their risk of heart disease and determine their need for aspirin chemoprevention. Dr. Pignone notes that the site has been very popular with over 25,000 hits. The site can be found at http://www.med-decisions.com.
If you have comments or
questions about this newsletter or its contents, please e-mail
alward@med.unc.edu. 
Program Co-Directors:
Russ Harris, MD, MPH and Linda Kinsinger, MD, MPH
Education Coordinator
& Editor: Amy L. Ward
Go to the Program on Prevention Homepage