Clinical Briefs



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Am Fam Physician. 2004 Apr 1;69(7):1809-1810.

Update on Pneumococcal Conjugate Vaccine Shortage

On February 13, 2004, the Centers for Disease Control and Prevention (CDC) recommended that physicians temporarily suspend routine use of the fourth dose of 7-valent pneumococcal conjugate vaccine (PCV7, marketed as Prevnar) when vaccinating healthy children. This action was taken to conserve vaccine and minimize the likelihood of shortages until Wyeth Vaccines, the only U.S. supplier of PCV7, restores sufficient production capacity to meet the national need. Since that recommendation, PCV7 production has been much less than expected because of continuing problems with the PCV7 vial-filling production line. Shipments have been delayed, resulting in spot shortages that might continue beyond summer 2004 and become widespread.

To ensure that every child is protected against pneumococcal disease despite the PCV7 shortage, the CDC, in consultation with the American Academy of Family Physicians, the American Academy of Pediatrics, and the Advisory Committee on Immunization Practices, recommends that all physicians temporarily discontinue administering the third and fourth dose of PCV7 to healthy children. Physicians should continue to administer the routine four-dose series to children at increased risk for severe disease. Unvaccinated, healthy children 12 to 23 months of age should receive a single dose of PCV7. For children older than two years, PCV7 is not recommended routinely.

Limiting healthy children to two doses of PCV7 will conserve vaccine and permit more children to receive at least two doses. More vaccine is expected to become available for distribution in May and June, but availability cannot be guaranteed.

Physicians should maintain lists of children for whom vaccine has been deferred so it can be administered when the supply allows. The highest priority for vaccination among children who have been deferred is children vaccinated with less than two doses who are younger than one year.

Because data on the long-term efficacy of three-dose or two-dose vaccine regimens are limited, physicians should consider the diagnosis of invasive pneumococcal disease in incompletely vaccinated children and are encouraged to report invasive pneumococcal disease after any regimen of pneumococcal conjugate vaccine to the CDC through state health departments. If a pneumococcal isolate is available from a vaccinated child, the CDC will perform serotyping to determine whether the type is included in the vaccine.

Additional information is available online at http://www.cdc.gov/nip/home-hcp.htm and by telephone, 404-639-2215. Updated information about the national PCV7 supply is available from the CDC at http://www.cdc.gov/nip/news/shortages/default.htm.

Strength Training Among Older Adults

The Centers for Disease Control and Prevention (CDC) has released a report determining the percentage and characteristics of older adults who perform strength training consistent with current recommendations. “Strength Training Among Adults Aged 65 Years—United States, 2001” appears in the January 23, 2004, issue of Morbidity and Mortality Weekly Report, and is available online at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5302a1.htm.

Strength training (also referred to as resistance training) enables adults to improve their overall health and fitness by increasing muscular strength, endurance, and bone density and by improving their insulin sensitivity and glucose metabolism. For adults older than 65 years (“older adults”), strength-training exercises are recommended (see accompanying box) to decrease the risk for falls and fractures and to promote independent living. The American College of Sports Medicine recommends that adults include strength training as part of a comprehensive physical activity program. A national health objective for 2010 is to increase to 30 percent the proportion of adults who perform, more than two days each week, physical activities that enhance and maintain muscular strength and endurance.

Approximately 12 percent of older adults, and 10 percent of adults older than 75 years report that they met the strength-training objective. According to the CDC, these findings underscore the need for programs that encourage older adults to incorporate strength training into their lives along with regular physical activity.

Approximately 11 percent of older adults report that they engage in strength training more than two days per week. Women were less likely than men to meet the objective. The likelihood of meeting the objective declines with advancing age and increases with level of education. Persons who are obese are less likely than those of healthy weight to meet the objective. Adults of fair or poor health are less likely to meet the objective than those in excellent health.

Among older adults categorized as physically active, 24.7 percent engage in strength training. Adults categorized as inactive and those categorized as insufficiently active are less likely to engage in strength training than persons in the physically active group. An estimated 5.6 percent of adults responding to a survey met the national objectives for both physical activity and strength training.

These results suggest the need for targeted programs to encourage certain older-adult populations (e.g., women and persons who are less educated, obese, or physically inactive) to increase strength training. These populations are similar to those previously identified among persons older than 18 years who were less likely to engage in weight lifting more than two days per week.

Between 1998 and 2001, the proportion of older adults who met the national objective for strength training increased from 10 percent in 1998 to 12 percent in 2001 among those 65 to 74 years of age, and from 7 percent to 10 percent among those 75 years and older. However, these prevalences remained less than one half the 2010 national target of 30 percent of the adult population. To increase strength training among older adults, the CDC calls for programs that address multiple factors, including increasing awareness of fitness benefits, affordability, physical limitations, accessibility (e.g., transportation), and fear of injury. Programs can be offered at places of worship, community centers, senior centers, schools, and fitness centers. Older adults also can perform strength training in their homes by using chair exercises as described in exercise guides, videos, and free information from the Internet, such as the information available from the American Academy of Family Physicians.

Pneumonia Calculator for PDAs

The Agency for Healthcare Research and Quality (AHRQ) has created a clinical decision-support tool for personal digital assistants (PDAs) designed to help physicians quickly determine whether patients with community-acquired pneumonia should be treated at home or in a hospital. The “Pneumonia Severity Index Calculator” can be downloaded from the AHRQ Web site at http://pda.ahrq.gov. The calculator is available in Palm OS, Pocket PC, and HTML formats.

Community-acquired pneumonia contracted outside a hospital or nursing home affects approximately 4 million Americans and costs approximately $10 billion annually to treat. Most of those costs (92 percent) are spent treating patients who have been hospitalized for care.

The calculator is based on a clinical algorithm produced in 1997 by the AHRQ-funded Pneumonia Patient Outcomes Research Team (PORT). The Pneumonia PORT developed and tested the algorithm to help physicians make treatment decisions. The algorithm has been validated in a broad, randomized controlled trial and was shown to be safe, cost-effective, and to improve satisfaction by enabling patients to be treated at home rather than in the hospital when appropriate. A sizable number of low-risk patients can be treated safely on an outpatient basis, but these patients must be accurately identified before such treatment is recommended.

Strength Training Recommendations for Older Adults

  • Exercises should be performed at least two days per week.

  • Certain exercises can be performed standing or seated.

  • Use hand and ankle weights, or resistance bands, or no weights at all.

  • If weights are used, start with 1 to 2 pounds and gradually increase the weight over time.

  • Perform exercises that involve the major muscle groups (e.g., arms, shoulders, chest, abdomen, back, hips, and legs) and exercises that enhance grip strength.

  • Perform eight to 15 repetitions of each exercise, then perform a second set.

  • Do not hold your breath during strength exercises.

  • Rest between sets.

  • Avoid locking joints in arms and legs.

  • Stretch after completing all exercises.

  • If at any time you feel pain, stop exercising.

Information from the National Institute on Aging.


Copyright © 2004 by the American Academy of Family Physicians.
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