POP- November 2000 Newsletter

We thought it would be interesting to investigate where the major party presidential candidates stand on specific health issues related to prevention. As you might imagine, finding details this specific was somewhat of a challenge.

Ensure that all children have access to affordable health insurance by 2005 by expanding eligibility in the Children's Health Insurance Program (CHIP). This would be achieved by eliminating cumbersome barriers to child enrollment in health insurance, linking the health insurance programs to school lunch programs and providing bonuses for states that enroll uninsured children and holding those that don't accountable.

Support initiatives to improve research, prevention and treatment of diseases such as Alzheimer's, Parkinson's disease, diabetes, heart disease, and HIV/AIDS.

A new cancer initiative includes launching a national program for early detection and treatment of colon cancer; funding a new Quality Cancer Care Investment Fund to develop new 'cancer care guidelines' to assist health care professionals and patients in making the best treatment decisions; focusing on cancer prevention, promoting healthy lifestyles and reinvigorating the commitment to stop children from smoking.

Fight the growing crisis of HIV/AIDS in the US, Africa and around the world. Significant increases in funding for prevention, medical and pharmaceutical treatment and other critical support, services for people living with HIV/AIDS has been proposed recently and Vice President Gore is committed to seeing that through and continuing to provide support for this effort.

Require HMO's to cover preventive screenings recommended by the National Institutes of Health, such as mammograms, colorectal screening and screenings for cervical and prostate cancer.

Expand Medicare to cover uninsured adults between the ages of 55 and 64 to increase their access to preventive and diagnostic care.

Provide all seniors with prescription-drug benefits- including 50% of all prescription drug costs (up to $5,000 per year) and a catastrophic plan that covers all costs after spending $4,000 out-of-pocket on prescription drugs.
For more on the Gore-Lieberman plan, go to http://www.gorelieberman.com/

Journal of the National Cancer Institute, Vol. 92, No. 21, 1709, November 1, 2000

Governor Bush's plan does not mention any prevention-specific issues. However, he does call for the following:

12,000 new community health centers to serve people in medically underserved and rural areas.

Return CHIP to a flexible block grant program.

A family health credit that would pay for 80% of the cost of a health insurance policy, up to $2,000 a year, for every family making less then $30,000.

Develop a prescription drug plan to cover costs over $6,000 annually for any senior. The drug plan will also cover all costs for seniors with incomes below 135 percent of poverty level and part of the costs for seniors between 135 and 175 percent of poverty level. If states already have a prescription drug plan in place, the funds can be used in ways to address specific state health care needs.
Go to http://www.georgewbush.com for more information.

Drazen, Jeffrey. The Republican and Democratic candidates speak on health care. NEJM. 2000;343:1184-1189.
Bush GW. Ensuring access to health care. The Bush plan. JAMA. 2000;284:2108-2109.
Gore A. Ensuring access to health care. The Gore plan. JAMA. 2000;284:2110-2111.

In the August newsletter, we reported a delay in the availability of the influenza vaccine for the 2000-01 season and the possibility of a vaccine shortage. Since then, resolution of manufacturing problems and improved yields of the influenza A (H3N2) vaccine component have averted a shortage. Although safe and effective influenza vaccine will be available in similar quantities as last year, much of the vaccine will be distributed later in the season than usual. This update provides information on the influenza vaccine supply situation and updated influenza vaccination recommendations by the Advisory Committee on Immunization Practices (ACIP) for the 2000-01 influenza season.

When influenza vaccine becomes available, vaccination efforts should be focused on persons at high risk* for complications associated with influenza disease and on health-care workers who care for these persons.

Temporary shortages because of delayed or partial shipments may require decisions on how to prioritize use of vaccine available early in the season among high-risk persons and health-care workers; such decisions are best made by those familiar with the local situation. Vaccine available early in the season should be used to maximize protection of high-risk persons. Because vaccine supplies are expected to increase substantially in November and December, plans should be made to continue vaccination of high-risk persons and health-care workers into December and later.

Mass vaccination campaigns should be scheduled later in the season as availability of vaccine is assured. Based on projected vaccine distribution, in most areas campaigns will be scheduled in November or later. Efforts should be made to increase participation by high-risk persons and their household contacts, but other persons should not be turned away.

Groups implementing mass vaccination efforts should seek to enhance coverage among those at greatest risk for complications of influenza and their household contacts. However, special efforts to vaccinate healthy persons in this age group should begin in December and continue as long as vaccine is available.

Vaccination efforts for all groups should continue into December and later as long as influenza vaccine is available. Production of influenza vaccine will continue through December, and providers should plan for how vaccine provided late in the season can be used effectively. Vaccination providers who administer all of their available influenza vaccine supply early in the season and who still have unvaccinated high-risk patients should order additional vaccine that will become available in December. To minimize wastage of influenza vaccine, providers whose initial vaccine orders are delayed or partially filled should not seek replacement vaccine from other manufacturers or distributors unless use of all vaccine doses ordered can be assured during the 2000-01 season.

Pneumococcal vaccines are recommended by ACIP for many of the same high-risk persons for whom influenza vaccine is recommended. Assuring pneumococcal vaccination of high-risk persons in accordance with ACIP recommendations early in the season will confer substantial protection from a major complication of influenza (pneumococcal pneumonia).

Annual influenza vaccination provides an opportunity to review the pneumococcal vaccination status of persons for whom pneumococcal vaccination is recommended by ACIP. This season, pneumococcal vaccine should be administered when indicated even if influenza vaccine is not yet available. Providers should emphasize to patients or their caregivers that pneumococcal vaccination is not a substitute for influenza vaccination and that patients need to return for influenza vaccine when it is available.

* Persons at high risk for complications from influenza are:

persons aged 65 years and older;

residents of nursing homes and other chronic-care facilities that house persons of any age who have chronic medical conditions;

children and adults who have chronic disorders of the pulmonary or cardiovascular systems, including asthma;

children and adults who have required regular medical follow-up or hospitalization during the preceding year because of chronic metabolic diseases (including diabetes mellitus), renal dysfunction, hemoglobinopathies, or immunosuppression (e.g., caused by medications or human immunodeficiency virus);

persons aged 6 months-18 years who are receiving long- term aspirin therapy and therefore might be at risk for developing Reye syndrome after influenza; and

women who will be in the second or third trimester of pregnancy during the influenza season.

Updated Recommendations from the Advisory Committee on Immunization Practices in Response to Delays in Supply of Influenza Vaccine for the 2000-01 Season. MMWR. October 6, 2000.

Preterm birth (less than 37 completed gestational weeks) is a leading cause of infant morbidity and mortality in industrialized countries around the world. Costs of caring for preterm infants are substantial. Most studies of morbidity and mortality among preterm infants have focused on those born very preterm, (ie, at gestational ages less than 32 weeks.) For infants born at 32 through 36 weeks, the risks are much lower, due to recent advances in neonatal intensive care. On the other hand, from a public health perspective, births at gestational ages of 32 through 36 weeks are much more common than those at less than 32 weeks.

To determine the contribution of mild and moderate preterm birth to the overall burden of infant mortality, researchers in the US and Canada linked singleton live birth-infant death files in the two countries. Their results were published in the August 16, 2000 edition of JAMA. They calculated the etiologic fraction (EF), also known as the population-attributable risk, for births at three time periods: 28 through 31 gestational weeks, 32 through 33 weeks (moderate preterm birth), and 34 through 36 weeks (mild preterm birth).

Risk and Etiologic Fraction of Infant Mortality by Gestational Age, Excluding Deaths Caused by Congenital Conditions (US 1995)

*Per 1000 live births
**Adjusted for maternal age, parity, race and education; reference age is 37 or more weeks
+Adjusted for maternal age and parity; reference age is 37 or more weeks.

Excluding congenital conditions (which are not caused by prematurity), these babies had increased mortality due to causes such as asphyxia, infection, SIDS, and external causes (eg, maltreatment and abuse). The sum of the EFs for 32-33 and 34-36 gestational weeks nearly equaled or exceeded those for infants born at 28-31 weeks. Even though the relative risk of death is lower for babies born between 32 and 36 weeks compared with those born earlier, the population impact of these deaths is larger, because of the larger number of births in this period.

Thus the authors conclude that obstetricians and pediatricians should keep these increased risks in mind when considering preterm induction or monitoring preterm infants. Public health and clinical research efforts to decrease infant mortality should include prevention of mild and moderate preterm births, as well as prevention of those born earlier.

Michael S Kramer, MD, Kitaw Demissie, MD, PhD, Hong Yang, MSc, Robert W. Platt, PhD, Reg Sauve, MD, MPH, Robert Liston, MD. The Contribution of Mild and Moderate Preterm Birth to Infant Mortality. JAM.A. 284(7):843-849.

We are delighted that all of the chapters in the Prevention Syllabus will be integrated into relevant first and second-year curriculum material during 2000-2001. Through a committed effort from the Program, Course Directors and faculty, we have accomplished this goal. This is just a first step on this process however. We feel that these messages must be repeated consistently throughout the four-years and tied to each other through a common thread. We continue to improve our integration efforts. A special thanks to all the faculty who are including prevention material this year.

The number of UNC medical students pursuing an MPH degree in the School of Public Health has steadily increased over the past seven years. Most students accomplish this by taking an extra year between the third and fourth years of medical school. Our program is responsible for counseling students on the MPH options.

Eighteen UNC medical students are pursuing an MPH degree during the 2000-2001 school year. The number of students pursuing the Health Care & Prevention (HC&P) option has steadily increased over the past four years. Students are distributed among the various programs in the following way: 7 HC&P; 5 EPID; 3 HPAA; and 3 MHCH.

From Dr. George Sheldon, Chair, Department of Surgery, and Ernest Grant, RN, MSN, Outreach Clinician in the Burn Center, comes this Learn-Not-To-Burn (LNTB) Program success story.

As a result of the LNTB Program and visits from the fire department, Avee Huffman, an 8 year old girl with Down Syndrome, remembered what to do when a fire started in her home.

On February 12th at 8:30am Avee discovered that a log had rolled out of the fireplace in her family's home and ignited pillows, carpeting and other materials on the floor. Her mother was in the shower while her sister and college roommate were asleep upstairs. Avee went upstairs and got her mom out of the shower taking her to the living room to show her the fire. Avee's mother extinguished the fire which was three to four feet in size by the time she got to the flames.

Avee's mom credits the fire and life safety training that Avee has received since preschool, with saving her family. All schools and pre-schools in Watauga County have LNTB in all grades and in each classroom. This fact along with at least annual visits by the Boone Fire Department are being credited with giving Avee the knowledge to act responsibly. Avee says that Fireman Mike told her what to do.

Health & Wellness Fund, from the Tobacco Settlement, Calling on a Prevention Representative

Prevention practitioners made a leap forward in their attempt to prevent smoking related deaths when the tobacco settlement was awarded in 1999. As you may know, the settlement has been split in several ways providing money to several groups of interest. Fifty percent of the money has been put into the Golden Leaf Foundation (http://www.goldenleaf.org) which will aid communities who are severely crippled by the settlement against tobacco. Of the remaining 50%, half will be put into the Tobacco Trust Fund that will be given directly to farmers who will suffer from the settlement. The remaining 25% will be put into a Health and Wellness Trust Fund established to develop a comprehensive plan to finance programs and initiatives to improve health and wellness of the people of North Carolina. Moneys from the Fund will be used for the following:

Address health needs of vulnerable and underserved NC populations.

Fund programs and initiatives including research, education, prevention and treatment of health problems in NC.

Develop a comprehensive, community-based plan to improve the health and wellness of people of NC with a priority on preventing, reducing and remedying the health consequences of tobacco use emphasizing youth tobacco use.

A commission will oversee the Health and Wellness Trust Fund and will consist of 18 members, none of which may be employed by or affiliated with tobacco product manufacturing. The Governor will appoint 6 members. One will be a person involved in public health, one in the health-care delivery system, a health-care practitioner and three at-large appointees. The President Pro Tempore of the Senate will also appoint 6 members who will include a person involved in tobacco-related care issues, a person involved in health promotion & disease prevention and a person involved in health research with the others being at-large appointees. Finally, 6 people will be appointed by the Speaker of the House of Representatives and will include one person involved with policy trends, one involved with health care for underserved populations, one involved with child health care with three additional at-large appointees. The Commission will be responsible for choosing grant applications that will receive funding, developing criteria for program evaluation and encouraging federal mandates targeting the reduction of youth access to tobacco products.

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.

Drkoop.com, the site that believes "the best prescription is knowledge", has a new section with health calculators for a variety of topics. The include fitness (ideal weight, BMI, etc.), diet and nutrition (carbohydrate, protein, fiber and fat), general health (cost of smoking, stress, sleep, etc.), teen health (sexual behavior, alcohol risk, etc.) and risk assessment calculators (type 2 diabetes, heart disease, asthma, etc). This site would be a great patient education tool with one-stop-shopping for many health concerns.
http://www.koop.com/tools/calculator/#

New York Online Access to Health website comes from the New York Academy of Health and is a collaborative effort of many national and local organizations. The site is a nice resource jam-packed with links to information for providers and patients from reputable medical organizations. The list of medical topics at this site is quite extensive and information is available in English or Spanish.
http://www.noah.cuny.org/

Look for our next edition of "An Ounce of Prevention" in January, 2001.
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

Gestational Age (weeks)	% of All Live Births		Crude Risk of Infant Death*		Relative Risk of Infant Death		% of all Infant Deaths
Gestational Age (weeks)	US 1995	Canada 1992-94	US 1995	Canada 1992-94	US 1995**	Canada 1992-94+	US 1995	Canada 1992-94
28-31	1.2	.06	37.2	5309	17.6	30.0	6.9	6.6
32-34	1.4	.08	10.8	24.3	5.3	17.7	2.2	3.9
34-36	7.6	4.9	4.9	5.7	2.5	3.2	4.3	4.5