Practice Guidelines: CDC Reports on End-stage Renal Disease in Patients with Diabetes - August 15, 2006

August 15, 2006 Table of Contents

Practice Guideline Briefs

Am Fam Physician.�2006�Aug�15;74(4):673-677.

ACIP Releases 2006-2007 Influenza Vaccination Recommendations

The Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention has issued updated guidelines for the use of influenza vaccine and antiviral agents for prophylaxis and treatment of influenza A. The full report was published in the July 28, 2006, issue of Morbidity and Mortality Weekly Report and is available at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr55e628a1.htm.

Changes from previous recommendations include the following:

TABLE 1
Recommended Dosages of Antivirals for Influenza Chemoprophylaxis and Treatment

	Age group (years)
Agent	1 to 6	7 to 9	10 to 12	13 to 64	65 and older
Oseltamivir (Tamiflu)
Chemoprophylaxis, influenza A and B	Dosage varies by child’s weight*	Dosage varies by child’s weight*	Dosage varies by child’s weight*	75 mg once daily	75 mg once daily
Treatment, influenza A and B†	Dosage varies by child’s weight‡	Dosage varies by child’s weight	Dosage varies by child’s weight	75 mg twice daily	75 mg twice daily
Zanamivir (Relenza)
Chemoprophylaxis, influenza A and B	Not recommended in children 1 to 4 years of age	Ages 5 to 9: 10 mg (two inhalations) once daily	10 mg (two inhalations) once daily	10 mg (two inhalations) once daily	10 mg (two inhalations) once daily
Treatment, influenza A and B	Not recommended	10 mg (two inhalations) twice daily	10 mg (two inhalations) twice daily	10 mg (two inhalations) twice daily	10 mg (two inhalations) twice daily

*—Chemoprophylaxis dosing for oseltamivir is 30 mg once daily in children weighing 15 kg (33 lb) or less; 45 mg once daily in children weighing more than 15 kg to 23 kg (50 lb, 10 oz); 60 mg once daily in children weighing more than 23 kg to 40 kg (88 lb); and 75 mg once daily in children weighing more than 40 kg.

†—A reduction in the dosage of oseltamivir is recommended for persons with creatinine clearance of less than 30 mL per minute.

‡—Treatment dosing for oseltamivir is 30 mg twice daily in children weighing 15 kg or less; 45 mg twice daily in children weighing more than 15 kg to 23 kg; 60 mg twice daily in children weighing more than 23 kg to 40 kg; and 75 mg twice daily in children weighing more than 40 kg.

Adapted from Centers for Disease Control and Prevention. Prevention and control of influenza. Recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep 2006;55(RR-10):28.

Neither amantadine (Symmetrel) nor rimantadine (Flumadine) should be used for chemoprophylaxis against influenza A because of recent data indicating widespread resistance of influenza viruses to these medications. Until susceptibility to these agents has been reestablished among circulating influenza A viruses, oseltamivir (Tamiflu) or zanamivir (Relenza) may be prescribed if antiviral treatment or chemoprophylaxis of influenza is indicated (Table 1).
Children 24 to 59 months of age and their household contacts and out-of-home caregivers should be vaccinated against influenza. This change extends the recommendations for vaccination of children so that all children six to 59 months of age are vaccinated annually (Table 2).
Previously unvaccinated children six months to less than nine years of age should receive two doses of influenza vaccine. Children six months to less than nine years of age who receive trivalent inactivated influenza vaccine should have a booster dose administered at least one month after the initial dose, before the onset of influenza season, if possible. Children five to less than nine years of age who receive live, attenuated influenza vaccine should have a second dose six to 10 weeks after the initial dose, before the influenza season, if possible. If a child six months to less than nine years of age was vaccinated for the first time during a previous influenza season but did not receive a second dose of vaccine in the same season, only one dose of vaccine should be administered this season.
Health care professionals should routinely offer influenza vaccine to patients throughout the influenza season, even after influenza activity has been documented in their communities.

TABLE 2
Persons for Whom Influenza Vaccination Is Recommended

Persons at high risk for influenza-related complications and severe disease

Children six to 59 months of age

Pregnant women

Persons 50 years of age and older

Persons of any age with certain chronic medical conditions

Persons who live with or care for persons at high risk

Household contacts who have frequent exposure to persons at high risk

Health care professionals

The 2006-2007 trivalent influenza vaccine virus strains include A/New Caledonia/20/1999 (H1N1)-like, A/Wisconsin/67/2005 (H3N2)-like, and B/Malaysia/2506/2004-like antigens. For the A/Wisconsin/67/2005 (H3N2)-like antigen, manufacturers may use the antigenically equivalent A/Hiroshima/52/2005 virus; for the B/Malaysia/2506/2004-like antigen, manufacturers may use the antigenically equivalent B/Ohio/1/2005 virus (Table 3).

TABLE 3
Approved Influenza Vaccines by Age Group, 2006-2007 Season

Vaccine*	Manufacturer	Availability	Age group	Number of doses	Route of administration
TIV (Fluzone)	sanofi pasteur	0.25 mL (prefilled syringe) 0.5 mL (prefilled syringe) 0.5 mL (vial) 5.0 mL (multidose vial)	6 to 35 months 36 months and older 36 months and older 6 months and older	1 or 2† 1 or 2† 1 or 2† 1 or 2†	IM‡ IM‡ IM‡ IM‡
TIV (Fluvirin)	Novartis Vaccine	0.5 mL (prefilled syringe) 5.0 mL (multidose vial)	4 years and older 4 years and older	1 or 2† 1 or 2†	IM‡ IM‡
TIV (Fluarix)	GlaxoSmithKline	0.5 mL (prefilled syringe)	18 years and older	1	IM‡
LAIV (FluMist)	MedImmune	0.5 mL (sprayer)	5 to 49 years	1 or 2�	Intranasal�

TIV = trivalent inactivated vaccine; IM = intramuscular; LAIV= live, attenuated influenza vaccine.

*—A 0.5-mL dose contains 15 mcg each of A/New Caledonia/20/1999 (H1N1)-like, A/Wisconsin/67/2005 (H3N2)-like, and B/Malaysia/2506/2004-like antigens. For the A/Wisconsin/67/2005 (H3N2)-like antigen, manufacturers may use the antigenically equivalent A/Hiroshima/52/2005 virus, and for the B/Malaysia/2506/2004-like antigen, manufacturers may use the antigenically equivalent B/Ohio/1/2005 virus.

†—Two doses administered at least one month apart are recommended for children six months to less than nine years of age who are receiving influenza vaccine for the first time.

‡—For adults and older children, the recommended site of vaccination is the deltoid muscle. The preferred site for infants and young children is the anterolateral aspect of the thigh.

�—Two doses administered at least six weeks apart are recommended for children five to less than nine years of age who are receiving influenza vaccine for the first time.

�—One dose equals 0.5 mL, divided equally between both nostrils.

CARRIE ARMSTRONG

CDC Reports on End-stage Renal Disease in Patients with Diabetes

The Centers for Disease Control and Prevention (CDC) has released a report detailing the incidence of end-stage renal disease (ESRD) in patients with diabetes. The report was published in the November 5, 2005, issue of Morbidity and Mortality Weekly Report and can be accessed at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5443a2.htm.

Diabetes mellitus is the leading cause of ESRD in the United States, accounting for 44 percent of new cases in 2002. The CDC analyzed data from 1990 to 2002 from the U.S. Renal Data System and the National Health Interview Survey. The number of persons beginning treatment for ESRD caused by diabetes mellitus (ESRD-DM) increased 162 percent from 1990 to 2002. The age-adjusted incidence of ESRD increased from 247 for every 100,000 persons with diabetes in 1990 to305 in 1996. In 1997, the incidence of ESRD dropped to 293 for every 100,000 persons with diabetes, and it dropped again to 232 persons in 2002.

This decline in the incidence of ESRD-DM varied by age, sex, race, and ethnicity. From 1990 to 2002, the age-adjusted incidence was higher among men than women and higher among blacks than whites. From 1997 to 2002, the age-adjusted incidence decreased significantly in women but not in men, and incidence decreased in whites but not blacks. Incidence among Hispanics did not change significantly. From 1997 to 2002, incidence decreased for persons younger than 65 years, increased 10 percent for persons 75 years and older, and did not change significantly for persons 65 to 74 years of age.

LISA GRAHAM

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