Practice Guidelines

Recommended Adult Immunization Schedule, United States, 2007

CARRIE ARMSTRONG

See related editorial on page 2027.

The recent licensure of the human papillomavirus (HPV) vaccine (Gardasil) and the approval of the combination tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis booster vaccine, adsorbed (Tdap; Adacel) resulted in the most significant changes to this year's adult immunization schedule. Additional changes have been made to the schedule to reflect new recommendations from the Advisory Committee on Immunization Practices (ACIP) for varicella, influenza, hepatitis B, and measles, mumps, and rubella (MMR) vaccination.

HPV vaccination has been added to the age-based schedule and to the medical and other indications schedule, with a yellow bar to indicate that the vaccine is recommended for women up to 26 years of age with all indications except pregnancy. A one-time dose of Tdap vaccine, which is recommended in persons 64 years and younger, also has been added to the age-based schedule and to the medical and other indications schedule, with a hatched yellow bar indicating that the vaccine is recommended in all indications except pregnancy.

In anticipation of a new recommendation for the use of zoster vaccine in persons 60 years and older, the purple bar for varicella vaccine has been shortened. The varicella footnote has been reworded in accordance with ACIP recommendations for administering a routine second dose for all adults without evidence of immunity.

A new column has been added to the medical and other indications schedule to clarify indications for hepatitis A and B vaccines. The indications "chronic liver disease" and "recipients of clotting factor concentrates" have been combined into a new column with a yellow bar indicating that these vaccines are recommended for all persons with these medical indications. The hepatitis B footnote has been revised to reflect recommendations to vaccinate all adults seeking protection from hepatitis B virus infection and to vaccinate adults in specific settings (e.g., sexually transmitted disease clinics).

The MMR footnote has been reworded to reflect ACIP recommendations to administer a second dose of vaccine to adults in certain age groups and with certain risk factors, and the influenza footnote has been revised to reflect recent ACIP recommendations to vaccinate close contacts of children up to 59 months of age.

Practice Guideline Briefs

Strength Training Levels Fall Short of National Goal

More U.S. men and women are currently engaging in strength training than in 1998, but the percentage of those who train at least twice per week is significantly lower than the national objective of 30 percent by 2010. The findings from the National Health Interview Survey (NHIS) were reported in the July 21, 2006, issue of Morbidity and Mortality Weekly Report (available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5528a1.htm).

The NHIS data showed that the age-adjusted prevalence of strength training two or more times per week increased significantly from 1998 to 2004 (from 17.7 percent to 19.6 percent). However, no additional progress has been made since 2001, when the greatest yearly increase was reported. Although women experienced a significant increase between 1998 and 2004, overall strength training levels among women remained lower than those among men.

The prevalence of strength training was lowest among persons 65 years and older; nonetheless, respondents in this age group experienced the largest increase from 1998 to 2004. Possible explanations for this increase include promotion of active lifestyles among older adults and programs that specifically promote strength training, such as the Growing Stronger and Strong-for-Life programs. Despite these gains, additional measures to promote strength training are needed. Strength training throughout life can sustain functional independence for activities of daily living, such as the ability to carry groceries, rise from a chair, or walk up a flight of stairs.

Based on the findings of the NHIS report, the Centers for Disease Control and Prevention recommends that additional opportunities for adults to engage in strength training be made available, especially in places where adults already pursue leisure-time physical activity (e.g., schools, community centers). The findings also underscore the need to increase education about the benefits of strength training in targeted adult populations.

CARRIE ARMSTRONG

CDC Releases Report on Rate of Autism in the United States

Autism is regularly classified with Asperger's syndrome and pervasive developmental disorder not otherwise specified to make up what are known as the autism spectrum disorders, which are diagnosed by observing developmental patterns and behaviors. The Centers for Disease Control and Prevention (CDC) conducted two surveys, the National Health Interview Survey (NHIS) and the National Survey of Children's Health (NSCH), to determine the prevalence of autism spectrum disorders. The report, "Mental Health in the United States: Parental Report of Diagnosed Autism in Children Aged 4-17 Years-United States, 2003-2004," was published in the May 5, 2006, issue of Morbidity and Mortality Weekly Report.

The report indicated that up to six per 1,000 children had a parent-reported diagnosis of autism. Parents who reported that their child had autism noted that the child had specialized needs and social, behavioral, or emotional symptoms.

The NHIS included 18,885 children and the NSCH involved 79,590 children. The survey results suggested that the prevalence of autism was four times as high for males compared with females, and the peak prevalence was noted in children six to 11 years of age. Children of Hispanic ethnicity had lower rates of diagnosed autism, but it was not known whether differences in etiologic or cultural factors and access to services for diagnosis and treatment affected this population.

Eighty-three percent of children whose parents reported a diagnosis of autism had moderate or high levels of difficulties (e.g., conduct problems, emotional symptoms) compared with 15 percent of children who did not have autism. Only 16 percent of children without autism had peer problems compared with 82 percent of children with an autistic disorder; and 65 percent of children with autism were hyperactive compared with 12 percent of children without autism.

About 94 percent of children who had autism had special health care needs that were expected to last 12 months or longer; and 90 percent of children with autism required additional medical, educational, and mental health services, or required counseling or treatment for a behavioral, developmental, or emotional problem compared with children of the same age who did not have autism.

Tracking patterns of development and observing behavior are the only ways to diagnose and assess autism in children, which makes establishing and tracking prevalence difficult. Therefore, family physicians may find multiple methods for case ascertainment to be helpful. The report also emphasizes that physicians should not use age, race, or ethnicity to infer potential etiologic associations.

SHERRI DAMLO