POP- August 2000 Newsletter

It's back to school time.
Soon we will welcome students back to begin another school year.
We encourage you to call on the Program on Prevention in your course development and teaching duties.
We are happy to provide assistance in incorporating prevention content into your courses.

It's just about time for flu season again, however things will be a different this year in terms of how the influenza vaccine is given. Over the past several years,the production and distribution of the influenza vaccine has increased substantially. In 1999 a total of 80-85 million doses of vaccine were produced. Unfortunately, because of an unusual mutation of the virus, there may be a shortage of the influenza vaccine this year, and what vaccine there is available may be delayed in shipping. Thus the CDC and ACIP (Advisory Committee on Immunization Practice) have issued additional Influenza vaccination recommendations specific to this issue.

Implementation of organized influenza campaigns should be delayed until early to mid-November.

Influenza vaccinations of persons at high risk for complications from influenza and their close contacts should proceed routinely during regular health-care visits.

Provider-specific contingency plans for an influenza vaccine shortage should be developed to maximize vaccination of high-risk persons and health-care workers.

In the US 70-76 million people are considered at high-risk for major complications from influenza infections. For these people (35 million persons older than 65, 33-39 million persons under 65 years with high-risk medical conditions and 2 million pregnant women) the following considerations, in addition to the above recommendations, should be emphasized.

There is still benefit to receiving the vaccine after mid-November. Providers should continue to vaccinate after this time.

Those persons at high-risk should receive the vaccine as is normally distributed.

Providers should minimize wastage of the vaccine.

Only persons aged 50-64 who are high-risk should receive the vaccine.

Those persons in close contact with people at high-risk, such as health-care workers, should be vaccinated.

If it becomes apparent that there will be a substantial vaccine shortage, the CDC and ACIP will make further recommendations.

Delayed Supply of Influenza Vaccine and Adjunct ACIP Influenza Vaccine Recommendations for the 2000-01 Influenza Season. MMWR. 2000;49:619-622.

The Centers for Disease Control and Prevention suggests that 70% of smokers want to quit smoking completely and 46% try to quit each year and more than 70% of smokers visit a health care setting each year. In addition, neglecting tobacco users costs thousands of patient lives and billions of dollars to health care systems each year. Smoker's desire to quit, the cost to patients and health care systems and the effective treatments now available make this a prime opportunity for health care systems and providers to take action at halting tobacco use and dependency.

The US Agency for Healthcare Research and Quality recently appointed a panel of 18 scientists, clinicians, consumers and methodologists to review the literature on this subject. The panel's report suggests that treating tobacco use and dependency through counseling and pharmacotherapy should be standard clinical practice. The new guidelines call for "brief and intensive tobacco cessation interventions as well as system-level changes designed to promote the assessment and treatment of tobacco use." Approximately 6000 peer-reviewed articles that deal with the subject were reviewed and served as the basis for more than 50 meta-analyses. The following evidence-based guidelines were developed:

Tobacco dependence is a chronic condition that warrants repeated treatment until long-term or permanent abstinence is achieved

Effective treatments for tobacco dependence exist and all tobacco users should be offered those treatments.

Clinicians and health care delivery systems must institutionalize the consistent identification, documentation, and treatment of every tobacco user at every visit.

Brief tobacco dependence is effective, and every tobacco user should be offered at least brief treatment.

There is a strong dose-response relationship between the intensity of tobacco dependence counseling and its effectiveness.

Three types of counseling were found to be especially effective - practical counseling, social support as part of treatment, and social support arranged outside of treatment.

Five first-line pharmacotherapies for tobacco dependence - sustained-release bupropion hydrochloride, nicotine gum, nicotine inhaler, nicotine nasal spray, and nicotine patch - are effective, and at least one of these medications should be prescribed in the absence of contraindications.

Tobacco dependence treatments are cost-effective relative to other medical and disease prevention interventions. Health insurance plans should include counseling and pharmacotherapeutic treatments as reimbursable benefits.

A Clinical Practice Guideline for Treating Tobacco Use and Dependence- A US Public Health Service Report. JAMA. 1000;283:3244-3254.

During June and July, seven rising second-year medical students were involved in the Prevention Education Program. Five students funded by the Program on Prevention, one student funded by NIH and one unfunded student were selected to participate. Students spent 8-weeks with a faculty advisor working on various prevention projects and were paid $2,000 for their work. Projects included:

Student

Advisor

Project

Afsaneh Pirzadeh

Carol Ford, MD

Spent time in ACC Pediatric clinic working on the teen health education and resource room. Spent time with Dr. Coyne-Beasley working on a research project. Talked with parents in the ED about injury prevention and provide injury and safety counseling.

Brian Uthlaut

Clay Bordley, MD

Did a systematic literature review on prevention interventions conducted in the ED setting. This will be used to make recommendations for our ED.

Daniel Ingram

Margaret Nusbaum, DO

Worked with existing data on addressing sexual concerns with women including a literature review and data analysis. A publication and/or presentation is the expected outcome.

Todd Poret

Rebecca Socolar, MD

Worked with the Healthy Steps program to improve well-child visits. This focused on children with behavioral and developmental issues. Work included survey distribution, collection and analysis and parent counseling.

*Krista Weber

John Boggess, MD

Worked with cervical cancer prevention study including a literature review and enrolling patients in clinical trial.

*Heather Holden

Kathy Tawney, PhD

Worked with patients with renal failure. Tested the accuracy, efficiency and applicability of a new device that measures vascular access pressures in end-stage renal disease patients.

Peter Kranz

Amy Ward

Developed two patient education rooms at two local UNC practices (Chatham Crossing and Chapel Hill North). Work included equipping the rooms with resources (web, audio, video, and literature), helping create an evaluation mechanism and develop experiences for future students.

A new aspect to this program involved an "end of the experience" poster/presentation day. Summer prevention students along with summer family medicine students and summer emergency medicine students came together on July 19 to share their "Works in Progress" with each other and interested faculty members. This provided an wonderful opportunity for students to talk about the work they've done and also gain valuable presentation and/or poster making experience. Thank you to the students and faculty who made this a wonderful morning! What a great way to wrap up the summer! We look forward to working with The Departments of Family Medicine and Emergency Medicine in summer to come. Posters put together by students will be on display in Berryhill hall during orientation week.

We have decided to redesign our approach to distributing and utilizing the Prevention Syllabus. We have been working diligently with Course Directors to ensure that all modules are integrated into the curriculum at appropriate spots. We have found that the majority of the material is most appropriate for second-year students.

In the past, all first-year medical students received the syllabus on the first day of class....with all their many other syllabi. This year we will not be distributing the Syllabus at the beginning of the year. Instead, we will give students the Introduction module during their Special Topics time in which we will be involved. Following that, modules will be distributed at the time they are assigned in individual classes. For example, the Counseling module will be used in ICM2 during Session 5 "Third Function" of the Medical Interview: Education, Negotiation & Motivation"" and the Screening module is used in Clinical Epidemiology. We feel that this approach will be more conducive to students using the material effectively.

Many of this year's HC&P class have already begun their coursework. HC&P students have the option of beginning their program in the summer or fall. Twelve of the 25 students entering the program began on July 5th with courses in "Medical Computing" and "Introduction to Health Systems." The other thirteen students will start classes on August 22. The group consists of:

7 UNC Medical Students

4 Duke Medical Students

2 Robert Wood Johnson Clinical Scholars

8 Fellows

2 Faculty

1 Other Medical Student

1 Resident

Drs. Kinsinger & Harris will teach PUBH 250 "Strategies of Prevention for Clinicians" again this fall. The class is a core requirement of HC&P students and focuses on the four main strategies of clinical prevention outlined in The Guide to Clinical Preventive Services as well as the role of clinicians in public education and advocacy. The course includes many guest lecturers as well as student presentations and is held Tuesday/Thursday 3:30-4:45pm.

Primary Prevention of Coronary Heart Disease in Women Through Diet and Lifestyle

A new study published July 6 in the New England Journal of Medicine emphasizes again the importance of the simple messages of prevention. The study followed (84,129) registered nurses free of cardiovascular disease, cancer, or diabetes for 14 years. During the study 1128 women had major coronary events (296 deaths and 832 nonfatal myocardial infarctions). Women who did not smoke, were not obese, consumed a small amount of alcohol, exercised 30 minutes per day, and consumed a diet low in saturated fat had more than 80% less risk of a major coronary event, compared with all other women. This was even after adjusting for family history, blood pressure, and cholesterol. Unfortunately, only 3% of the women fell into this group. 82% of the coronary events that took place were among individuals not adhering to the low-risk lifestyle.

These results agree with other studies among other populations. While pharmacologic treatment of hypertension and high cholesterol is important in preventing coronary artery disease, these studies show that lifestyle patterns are also a potent tool.

Keep your blood pressure and cholesterol under control, but don't forget your mother's advice about lifestyle!

Meir J. Stampfer, MD, Frank B. Hu, MD, JoAnn E Manson, MD, Eric B. Rimm, ScD, and Walter C. Willett, MD. Primary Prevention of Coronary Heart Disease in Women Through Diet and Lifestyle. N Engl J Med 1000;343:16-22.

People have more access to health care information than ever before. Not only do they hear about health news in the media but more and more individuals are looking to the WWW for information. There is a whirlwind of information out there but directing your patients to credible and reliable information is the key. The Web can be a valuable resource for educational material for patients and providers alike if it is used wisely.

The Natural Pharmacist provides an in depth look at herbal supplements. It is written for patients and has a comprehensive list of herbal supplements available today. A page for each supplement includes common uses, the scientific evidence for or against, dosage information, safety issues and interactions you should know about. It also has a spot for professionals to become members and have access to a comprehensive professional-level guide to current information on herb-drug interactions. http://tnp.com/substanceshome.asp

MD Consult, "the Web's only site designed exclusively to deliver authoritative medical information to physicians." Once a member, this site give you access to a plethera of medical information "from medical books, journals and other unimpeachable sources that have always served as your best second opinion." http://www.mdconsult.com/

Look for our next edition of "An Ounce of Prevention" in October, 2000.
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