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Am Fam Physician. 2002;65(8):1690-1696

CDC Report on U.S. Incidence of Malaria

According to the Centers for Disease Control and Prevention (CDC), the majority of malaria infections in the United States affect persons who have traveled to areas with endemic transmission. Infection may also occur through exposure to infected blood products, by congenital transmission, or by local mosquito-borne transmission. To identify episodes of local transmission and to guide prevention recommendations for travelers, the CDC conducted a malaria surveillance of infected persons with an onset of symptoms during 1998.

The CDC received reports of 1,227 cases of malaria with onset of symptoms in 1998 among persons in the United States and its territories. Of these cases, 98 percent were classified as imported, with 60 percent acquired in Africa, 20 percent in Asia, and 19.1 percent in the Americas.

Of the 584 U.S. civilians who had imported malaria and whose information about the use of chemoprophylaxis and area of travel was known, 59.4 percent had not taken any chemoprophylaxis and 13.4 percent had not taken the CDC-recommended drug for the area(s) visited. Only 21.6 percent had taken a medication recommended by the CDC. The purpose of travel to malarious areas was reported for 495 U.S. civilians with imported malaria. Of these cases, 38.5 percent occurred among persons who were visiting friends or relatives in malarious areas, 11.6 percent had traveled for tourism, and 10.1 percent had traveled for business purposes.

Malaria surveillance is important because the emergence of drug resistance and consequent failure of chemoprophylaxis must be monitored. Four deaths were attributed to malaria in the United States in 1998. None of the patients had taken prophylaxis and most had delays in treatment. Therefore, prompt diagnosis and treatment are vital.

“Malaria Surveillance—United States, 1998” appears in the December 7,2001 issue of the CDC Surveillance Summaries series of Morbidity and Mortality Weekly Report.

ACOG Committee Opinion on Exercise in Pregnancy

The Committee on Obstetric Practice of the American College of Obstetricians and Gynecologists (ACOG) has issued a statement on exercise during pregnancy and the postpartum period. ACOG Committee Opinion No. 267 appears in the January 2002 issue of Obstetrics and Gynecology.

According to the ACOG committee, the physiologic and morphologic changes that occur during pregnancy may interfere with a woman's ability to participate safely in some forms of physical activity. While participation in a variety of recreational activities is generally safe during pregnancy, activities with a high risk of falling or abdominal trauma should be avoided. When no medical or obstetric complications are present, pregnant women should aim for 30 minutes or more per day of moderate exercise.

The ACOG committee makes the following conclusions and recommendations regarding exercise during pregnancy:

  • Recreational and competitive athletes with uncomplicated pregnancies can stay active during pregnancy while modifying their usual exercise routines as medically indicated. Because information on strenuous exercise in pregnancy is scarce, women who participate in such activities should be closely medically supervised.

  • Women who were previously inactive and those with medical or obstetric complications should be evaluated before recommendations for physical activity during pregnancy are made. Exercise during pregnancy may provide additional health benefits to women with gestational diabetes.

  • A physically active woman with a history of, or risk for, preterm labor or fetal growth restriction should be advised to reduce her activity in the second and third trimesters.

Botulinum Toxin-A for Neuromuscular Pain

The Health Technology and Advisory Committee (HTAC) has published a report on the use of botulinum toxin-A for pain associated with neuromuscular disorders. HTAC was established in 1992 by the Minnesota state legislature. It is an independent, nonpartisan advisory body that evaluates new and emerging health care technologies based on existing scientific research and technology assessments.

According to the HTAC report, botulinum toxin-A is injected directly into affected muscles to produce chemical denervation of the abnormally functioning muscles by blocking synaptic transmission. The effects are dose dependent and last for two to six months. Most patients require repeated injections to maintain the beneficial effects.

HTAC examined the use of botulinum toxin-A in a number of neuromuscular conditions. Clinical applications that are not approved by the U.S. Food and Drug Administration (FDA) but where data exist to support the use of botulinum toxin-A include spasmodic torticollis, focal hand dystonia, spasmodic dysphonia, dynamic contracture in patients with cerebral palsy, post-stroke spasticity myofascial pain syndrome, and chronic low-back pain. The FDA has already approved botulinum toxin-A for the treatment of patients with cervical dystonia, and strabismus and blepharospasm associated with dystonia.

Treatment with botulinum toxin-A can be painful. It should not be used in persons with an infection at the injection site or in persons known to be hypersensitive to any ingredient in the drug. Botulinum toxin-A should be used with caution in patients with peripheral motor neuropathic diseases or neuromuscular junctional disorders, or who are receiving aminoglycosides or other agents that interfere with neuromuscular transmission.

This report and others published by HTAC may be obtained by calling 651-282-6374 or by e-mail ( There is no charge for the reports. All reports are also available on the HTAC Web site

FDA Approves Procleix HIV-1/HCV Assay

The U.S. Food and Drug Administration (FDA) has recently approved the first nucleic acid amplification test for screening donors of whole blood and blood components to be used in transfusion. The Procleix HIV-1/HCV Assay is able to detect all known human immunodeficiency virus type 1 (HIV-1) subtypes and hepatitis C virus (HCV) genotypes in whole blood during the very early stages of infection, when these agents are present but cannot be detected by immunodiagnostic screening technologies. The system is also approved for screening donors of plasma for specific use in products such as clotting factors and immune globulins.

The FDA reports that the Procleix HIV-1/HCV Assay is able to detect more infectious blood samples than current tests because of its ability to detect viral genes rather than antibodies or antigens. Detection of viral genes allows detection earlier in the infection because the appearance of antibodies takes time for the donor to develop an immune response, and because detection of antigens requires time for a higher level of virus to appear in the bloodstream.

Donors of blood and plasma are currently tested for antibodies to HCV, antibodies to HIV, and HIV-1 antigens. However, some infected donations can be missed because of the “window period” during which a donor can be infected but have negative screening results.

According to the manufacturer, the Procleix HIV-1/HCV Assay has been used to screen more than 20 million blood donations from U.S. blood banks since March 1999. Of these, seven HIV-1-positive and 88 HCV-positive donations have been identified that would have otherwise entered the blood supply.

For more information on the Procleix HIV-1/HCV Assay, visit the FDA Web site or the manufacturer's Web site

Vaccine Shortages and Delays Continue in 2002

The Centers for Disease Control and Prevention (CDC) reports that the vaccine shortages of 2001 are expected to extend through the summer of 2002. Vaccines in short supply include varicella; measles, mumps, and rubella; diphtheria/tetanus/acellular pertussis; and pneumococcal conjugate vaccine.

According to the CDC, reasons for the shortage include production delays and government regulations that banned use of thimerosal, a common preservative previously used in vaccines. Also, with some manufacturers leaving the market, supply and demand issues have arisen.

Because of the shortage, the CDC has temporarily revised some of its recommended immunization schedules. For example, infants are normally immunized at 12 months and 18 months of age with varicella vaccine, but the CDC now recommends giving the vaccine at 18 months and 24 months. For updated information on the shortages and delays of these vaccines, visit the CDC Web site or the Web site of the American Academy of Family Physicians

AHRQ Guide to Clinical Preventive Services

The Agency for Healthcare Research and Quality (AHRQ) has released a new publication titled, “A Step-by-Step Guide to Delivering Clinical Preventive Services: A Systems Approach.” The guide is part of AHRQ's Put Prevention Into Practice program, and is intended to help guide health care professionals in developing a system for delivering clinical preventive services in the primary care setting.

According to the AHRQ, the guide is based on scientific and empirical evidence and has proved effective in many settings. The guide describes easy-to-follow, logical steps for establishing preventive care protocols; defines staff roles for delivering and monitoring preventive care; determines patient and material flow; and readjusts delivery and system standards. The process of developing a clinical preventive services program is broken down into small, manageable tasks. Practical tools such as worksheets, health risk profiles, and preventive care flow sheets are provided and can be customized for use in various clinical settings.

Copies of the guide may be obtained from the AHRQ Publications Clearinghouse by calling 800-358-9295 or sending an e-mail request to The guide is also available on the AHRQ Web site

FDA Approval of New Anti-Clotting Drug

The U.S. Food and Drug Administration (FDA) recently approved fondaparinux sodium (Arixtra) injection for reducing the risk of deep venous thrombosis following orthopedic surgery for hip fracture, hip replacement, and knee replacement. According to the FDA, fondaparinux injection is the first synthetic anticoagulant indicated for use in these types of surgeries.

Fondaparinux inhibits Factor Xa, which can lead to blood clots in the deep veins of the legs following surgery. The main side effects of fondaparinux are bleeding complications. Patients who weigh less than 50 kg (110 lb) or who have severely impaired renal function (creatinine clearance less than 30 mL per minute) should not be given fondaparinux because they may be at increased risk for serious bleeding. Elderly patients may also be more likely to have serious bleeding complications. The labeling for fondaparinux includes a warning that patients taking fondaparinux who undergo spinal anesthesia or spinal puncture have a risk of developing a blood clot in the spine, which can lead to permanent paralysis.

For more information on fondaparinux, visit the FDA Web site

Physical Activity in Infants, Toddlers, and Preschoolers

The National Association for Sport and Physical Education (NASPE) recently released a set of physical activity guidelines for infants, toddlers, and preschoolers. According to the NASPE, becoming physically active early in life is essential because it increases the likelihood that infants and young children will learn to move skillfully, ensures healthy development, and lessens the chance of developing sedentary habits and childhood obesity.

The infant guidelines involve a parent or caregiver planning physical activity with a variety of baby games, such as peekaboo and pat-a-cake, and sessions in which the child is held, rocked, and carried to new environments. The infant guidelines are:

  • Infants should interact with par ents and/or caregivers in daily physical activities that promote the exploration of their environment.

  • Infants should be placed in safe settings that facilitate physical activity and do not restrict movement for long periods of time.

  • Physical activity in infants should promote the development of movement skills.

  • Infants should have an environment that meets or exceeds the recommended safety standards for per forming activities that involve large muscle groups.

  • Persons responsible for the care of infants should be aware of the importance of physical activity and facilitate the child's movement skills.

For toddlers, basic movement skills such as running, jumping, throwing, and kicking emerge from an interaction between hereditary potential and movement experience, and are also influenced by the child's environment. The guidelines for toddlers and preschoolers are:

  • Toddlers need at least 30 minutes and preschoolers need at least 60 minutes of structured physical activity daily.

  • Toddlers and preschoolers need from 60 minutes to several hours per day of unstructured physical activity and should not be sedentary for more than 60 minutes at a time unless they are sleeping.

  • Toddlers should develop movement skills that are building blocks to more complex movement tasks; preschoolers should develop competence in movement skills that are building blocks to more complex movement tasks.

    Toddlers and preschoolers should have indoor and outdoor areas available for them to play in that meet or exceed recommended safety standards for performing activities that involve the large muscle groups.

  • Persons responsible for the care of toddlers and preschoolers should be aware of the importance of physical activity and facilitate the child's movement skills.

For more information, call the NASPE at 800-321-0789 or visit the Web site of the American Alliance for Health, Physical Education, Recreation and Dance

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Copyright © 2002 by the American Academy of Family Physicians.

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