2014: Year in Review

Ebola, Vaccination Changes Dominate Past Year's Headlines

January 05, 2015 10:48 am News Staff

In one form or another, family medicine played a major role in 2014's top medical stories, including the Ebola outbreak in West Africa and changes to immunization recommendations that affected young children, as well as adults 65 and older.

During his speech at the AAFP Assembly on Oct. 24, AAFP member Kent Brantly, M.D., explains that he "moved to Liberia not simply to save lives but also to replace hopelessness with hope."

The summer of 2014 marked the first time the entire world took notice of the Ebola outbreak in West Africa and the destruction left in its wake. AAFP News' first mention of the outbreak in April guided family physicians to resources HHS had developed about the disease and how to recognize it.

Further coverage in August included information from family physician and CDC Advisory Committee on Immunization Practices (ACIP) Chair Jonathan Temte, M.D., Ph.D., of Madison, Wis., regarding the typical incubation period for the disease. "If Ebola is suspected based on travel and/or exposure history, patient isolation and immediate communication with public health authorities are key elements of containment," he said.

In October, family physician disaster preparedness experts offered advice on how to prepare for Ebola in a family medicine practice, and the CDC provided an Ebola Algorithm(www.cdc.gov) to use when evaluating travelers returning from affected areas.

Perhaps most notable was the fact that the first American to survive an Ebola infection contracted while serving as a medical missionary at ELWA (Eternal Love Winning Africa) Hospital in Monrovia, Liberia, was an AAFP member.

Kent Brantly, M.D., told his survival story to a packed ballroom during the 2014 AAFP Assembly in Washington in October. Before that event, he sat down with AAFP News to discuss family medicine, his experience battling Ebola and his ideas for controlling the outbreak that even now continues to rage in West Africa.

For his work helping patients combat the disease, as well as for his unflagging calls for international support in halting its spread, Brantly was included in Time magazine's "Ebola Fighters" Person of the Year story in December.

Other Disease Outbreaks

Even as Ebola scorched through much of West Africa, other viruses rapidly swept across the United States.

Although previously considered eliminated, measles once again reared its ugly head in 2014. As of May 30, a total of 334 confirmed cases in 18 states had been reported, with the largest outbreaks in Ohio and California. Importation from hard-hit Philippines, paired with U.S. parents' refusal to immunize their children against the disease, were blamed for the resurgence.

Next up was pertussis. As of June 16, 9,964 cases of pertussis had been reported to the CDC by 50 states and Washington, D.C. The agency said this represented a 24 percent increase compared with the same period in 2013. Vaccinating pregnant women with tetanus, diphtheria and acellular pertussis (Tdap) to protect infants too young for the diphtheria and tetanus toxoids and acellular pertussis adsorbed vaccine was recommended to protect the most vulnerable group affected by the outbreak.

Then in August, another puzzling outbreak -- this one involving enterovirus D68 -- started in the Midwest but eventually spread coast to coast. In October, the medical community began to hypothesize that this less common enterovirus type was responsible for an acute neurologic illness characterized by extremity weakness, cranial nerve dysfunction (e.g., diplopia, facial droop, dysphagia or dysarthria), or both.

Vaccines and Immunizations

The biggest vaccine and immunization stories of 2014 involved recommending the use of live attenuated influenza vaccine (LAIV) in young children and 13-valent pneumococcal conjugate vaccine (PCV13) in adults 65 and older.

In June, the CDC's Advisory Committee on Immunization Practices (ACIP) met and decided to preferentially recommend LAIV over inactivated influenza vaccine for healthy children ages 2-8.

This young girl is receiving the live attenuated influenza vaccine.

But at the ACIP's October meeting, committee members reviewed data from the U.S. Flu Vaccine Effectiveness Network that suggested the LAIV vaccine had not been effective against the influenza A (H1N1) virus in children during the 2013-14 influenza season. Consequently, the group now plans to re-evaluate its LAIV recommendation at its February meeting, taking into account both the previous evidence and preliminary data collected from the 2014-15 season, and may adjust the recommendation accordingly.

Also during the June ACIP meeting, discussion began on recommending PCV13 versus pneumococcal polysaccharide vaccine (PPSV23) for older adults. Although PPSV covers more types of pneumococcal bacteria, PCV13 confers longer-lasting protection.

After convening a special meeting on Aug. 13 the group decided to recommend the PCV13 vaccine, marketed by Pfizer Inc. as Prevnar 13, to adults age 65 or older who have not previously received a pneumococcal vaccine or whose previous vaccination history is unknown.

Drifted Influenza A (H3N2) Presages Bad Flu Season

In early December, AAFP News reported that the CDC had announced influenza A (H3N2) viruses were the predominant strains circulating during the early stages of the 2014-2015 flu season. The announcement foreshadowed the agency's subsequent declaration that the flu had reached epidemic levels, sweeping through more than 40 states and continuing to spread into the nascent new year.

Unfortunately, of the H3N2 viruses collected and analyzed, 52 percent were antigenically different, or had drifted, from the H3N2 vaccine virus, according to a CDC Health Alert Network advisory(emergency.cdc.gov).

In light of the H3N2 virus drift, the advisory re-emphasized the importance of using neuraminidase inhibitor antiviral medications when indicated to treat and prevent influenza as an adjunct to vaccination.

And despite the suboptimal vaccine match, said AAFP liaison to the Advisory Committee on Immunization Practices Jamie Loehr, M.D., of Ithaca, N.Y., "We still recommend flu vaccine for everyone older than age 6 months; we still recommend meds for certain patients with flu, as well. What this says is that there is drift and that the drifted strains not covered by the vaccine are sensitive to the medicines (i.e., no resistance seen), so you should use the medicines in appropriate cases."

The recommendation statement also noted that physicians should recommend a dose of PPSV23, marketed by Merck and Co. as Pneumovax, for these patients six to 12 months after PCV13 vaccination. Finally, the committee recommended that if a patient 65 or older has not previously received the PCV13 vaccine but has received one or more doses of PPSV23, that patient should receive a dose of PCV13 at least one year after administration of the most recent dose of PPSV23.

In late July, the CDC released a Morbidity and Mortality Weekly Report (MMWR) that included the 2013 National Immunization Survey-Teen (NIS-Teen), which found that the number of adolescents ages 13-17 who have received any doses of the HPV vaccine remains "unacceptably low." In 2013, that number was 57 percent of adolescent girls and 35 percent of boys. For reference, 86 percent of all adolescents received one dose of Tdap vaccine during that period.

To help reverse this trend, the Academy offered its Child and Adolescent Immunization Office Champions Project to aid participating practices in improving their overall office immunization rates. The final report was published in September. Child immunization rates included a 6.78 percent increase over baseline in vaccination for hepatitis A, and slight increases in vaccinations for varicella (2.27 percent), rotavirus (1.43 percent) and measles, mumps and rubella (1.08 percent). Adolescent immunization rate changes over baseline ranged from 12.35 percent for Tdap to 100 percent for at least one dose of HPV vaccine.

Clinical Preventive Service Recommendations

The U.S. Preventive Services Task Force (USPSTF), with input from the AAFP, issued a number of recommendations to guide primary care practices in 2014.

In August, the USPSTF offered a B recommendation for behavioral counseling to promote a healthy diet and physical activity for cardiovascular disease (CVD) prevention in adults at high risk for the disease. AAFP News first covered the recommendation when it was in its draft stage in June.

USPSTF Chair and family physician Michael LeFevre, M.D., M.S.P.H., of Columbia, Mo., suggested at the time that the recommendation regarding these types of behavioral counseling programs could lead to more of them being established across the country. Insurance companies might start to notice and support them, which would lead to additional programs.

"If the payers follow, and start to reimburse for this type of counseling, that makes it much more likely these types of programs will continue to develop," LeFevre said.

Among other recommendations were the following:

  • In February, the AAFP and the USPSTF recommended against using beta-carotene or vitamin E supplements to prevent CVD or cancer. The AAFP also agreed with the USPSTF that evidence currently is insufficient to assess the balance of benefits and harms of using multivitamins or single- or paired-nutrient supplements (with the exception of beta-carotene and vitamin E) to prevent these conditions.
  • In May, the Academy and the task force recommended screening for hepatitis B virus (HBV) infection in people at high risk for infection. The groups also continued to recommend against screening the low-risk, general asymptomatic population for chronic HBV infection.
  • In June, the AAFP and the USPSTF both recommended one-time screening for abdominal aortic aneurysm (AAA) using ultrasonography in men ages 65-75 who have ever smoked. Both groups concluded that current evidence is insufficient to assess the balance of benefits and harms of screening for AAA in women ages 65-75 who have a smoking history.
  • In July, the two groups recommended against screening for asymptomatic carotid artery stenosis (CAS) in the general adult population.
  • In September, the AAFP and the task force recommended that pregnant women at high risk for pre-eclampsia should use low-dose aspirin (81 mg/day) after 12 weeks' gestation to prevent the condition and its related health problems.
  • In November, the Academy and the USPSTF concluded that current evidence is insufficient to assess the balance of benefits and harms of screening for vitamin D deficiency in asymptomatic adults. AAFP News covered the release of the draft recommendation in July.
[Doctor taking obese, black male's blood pressure]

Endorsed Guidelines

The Academy also endorsed a number of other organizations' guidelines this past year.
Probably the most notable of these was the AAFP's September endorsement of a hypertension guideline from panel members appointed to the Eighth Joint National Committee that addressed initiating and modifying pharmacotherapy for patients with elevated blood pressure. First published online in December 2013 by JAMA: The Journal of the American Medical Association, the guideline outlined nine specific treatment recommendations.

The AAFP also took the following action on other organizations' guidelines:

  • In June, the AAFP posted its qualified endorsement of the American College of Cardiology (ACC) and American Heart Association (AHA) guidelines on treatment of high cholesterol to reduce atherosclerotic cardiovascular risk in adults.
  • In August, the AAFP endorsed a guideline for identifying, evaluating and treating obesity in adults that was developed by the ACC, the AHA and the Obesity Society.
  • That same month, the AAFP gave its qualified endorsement to the third in a series of ACC and AHA guidelines, this one focusing on reducing cardiovascular risk in adults through lifestyle management. The guideline was published online November 2013 by the AHA journal Circulation.
  • In September, the AAFP endorsed an updated guideline from the American Academy of Otolaryngology-Head and Neck Surgery Foundation that provided evidence-based recommendations for managing acute otitis externa.

Public Health Roundup

The AAFP tackled three other key issues during 2014: tobacco control, opioid abuse, and integrating primary care and public health.

In February, the Academy released the final report from its 2013 Office Champions Tobacco Cessation Project, which was implemented at 22 federally qualified health centers. Launched as a 13-month pilot project in June 2010, the initiative's most recent findings demonstrate that it continues to boost medical practices' tobacco-cessation activities.

An AAFP Youth & Tobacco Prevention Summit in April generated partnerships with other tobacco prevention and cessation groups and eventually led to the reimagining of the Academy's Tar Wars program.

Also in April, the FDA announced its intention to to extend the agency's authority to regulate tobacco products. Specifically, the agency would "deem" currently unregulated products -- including electronic cigarettes, cigars, pipe tobacco, nicotine gels, waterpipe (or hookah) tobacco, and dissolvables -- as meeting the statutory definition of "tobacco product," therefore rendering them subject to FDA regulatory authority under the Family Smoking Prevention and Tobacco Control Act.

After closely scrutinizing the FDA proposal, the Academy joined with other groups that summer in supporting the agency's move.

Finally, the Academy announced in August that it was developing a comprehensive tobacco and nicotine prevention and control program that would be broader in scope than its current activities. The program is expected to encompass new office-based tools, community programs, and advocacy at the national and community levels.

To address the nation's raging opioid abuse problem, in March, the AAFP joined a coalition of health industry stakeholders in issuing a consensus statement that outlined collaborative steps the groups planned to take to ensure the delivery of responsible and effective patient care when it comes to prescribing and dispensing controlled substances.

In July, the CDC issued Vital Signs and MMWR reports that addressed the overprescribing of opioids in the United States. According to the MMWR report, in 2012, prescribers wrote 82.5 opioid pain reliever and 37.6 benzodiazepine prescriptions per every 100 people in the United States.

Also in July, AAFP News examined how family physicians like Hughes Melton, M.D., of Bristol, Va., were leading the fight to turn the tide of opioid abuse.

Melton is the medical director and founder of HighPower P.C., a patient-centered medical clinic that specializes in addiction treatment and pharmacy consultative services related to mental health and women's health. The clinic also offers primary care to a small group of patients. Drawing on the group approach to therapy long used during addiction recovery, Melton said he decided to see substance abuse patients in a group setting rather than in individual sessions, partly because there were initially many patients and only one of him.

In September, the DEA published a final rule that moved hydrocodone combination products from Schedule III to the more restrictive Schedule II, as was recommended by the HHS assistant secretary. The rule took effect on Oct. 6.

A study in December brought good news in the opioid abuse battle, finding that 45 percent of physicians responding to a survey said they are less likely to prescribe opioids than they were one year ago.

On the integrating primary care and public health front, the Academy participated in a number of efforts to promote the concept.

Back in March, the AAFP joined a diverse group of public and private organizations in helping to launch the Practical Playbook initiative, which offers online resources to help primary care and public health professionals in their efforts to integrate with one another.

In November, the same team unveiled its next initiative -- the BUILD Health Challenge -- that provided grant and loan funding to foster and expand meaningful partnerships among health systems, community-based organizations, local health departments and other organizations that affect community health.

Finally, in December, the Academy stepped up its promotion of this synergistic idea by publishing its own position paper titled "Integration of Primary Care and Public Health." The position paper outlines the family physician's role in these efforts.

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