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Hand Washing CDC Recommends Routine HIV Screening Regardless of Patient Risk Dispensers Can
BY ROBERT FINN

San Francisco Bureau

he Centers for Disease Control and Prevention has recommended that voluntary HIV screening be a routine part of medical care for all patients between the ages of 13 and 64 years. The recommendations are intended to simplify the HIV testing process in health care settings and to increase HIV diagnosis among an estimated 250,000 Americans who are HIV positive but remain unaware of their infection. “There are some things that never should happen,” Dr. Julie L. Gerberding, the CDC’s director, said during a press briefing. “No child in the United States should be HIV infected from birth. No person in the United States should [lack] access to treatment or diagnosis. And ultimately no person in the United States should acquire HIV infection.” Studies show that almost 40% of individuals diagnosed with HIV receive that diagnosis within a year of the infection progressing to AIDS, and presumably about 10 years after they were initially infected. Often, this is too late for them to fully benefit from treatment. Furthermore, it is estimated that people who are unaware of their infection account for 50%-70% of new sexually transmitted HIV infections. People who are aware of their HIV infections typically take steps to protect their partners. The recommendations, slated for publication in the Sept. 22, 2006 issue of the CDC’s Morbidity and Mortality Weekly Report, are intended for any health care facility in the public or private sector that currently conducts diagnostic testing or screening. These facilities include hospital emergency departments, urgent care clinics, inpatient services, substance abuse treatment clinics, public health

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clinics, community clinics, correctional health care facilities, and primary care settings. The new recommendations do not apply to nonclinical settings, such as community centers or outreach programs. Earlier recommendations, published in 1993 and 2001, called for HIV testing in patients with known risk factors or in communities with HIV prevalence rates above 1%. But many facilities do not have information on local HIV prevalence, and many providers report that they do not have time to conduct risk assessments. Requirements for separate written con‘No person in the United States should [lack] access to treatment or diagnosis.’
DR. GERBERDING

sent for HIV testing and for pretest counseling also placed barriers in the path of testing. The new recommendations mandate a voluntary “opt-out” approach, in which patients would be specifically informed that HIV testing is part of routine care. All patients would be screened regardless of risk, pretest counseling would not be required, and posttest counseling would generally be required only for patients with a positive test result. Also included are recommendations aimed at enhanced screening of pregnant women. Existing recommendations for screening in this population have been remarkably successful in preventing mother-to-child HIV transmission: The number of infants born with HIV has declined from about 1,650 in

1991 to fewer than 240 per year today. In an effort to decrease that number further, the CDC is recommending that repeat HIV testing be provided in the third trimester for all women in areas with high HIV prevalence, not just for women at high risk for HIV. Furthermore, a rapid HIV test should be used during labor for all women whose HIV status remains unknown at the time of delivery. The CDC expects health care facilities to begin phasing in routine testing immediately, but the agency plans to issue additional guidance for health care providers in early 2007 that will provide examples of model approaches and practical tools for implementation in various types of health care settings. It’s expected that most patients would be screened a single time but that patients with known risk factors would be screened annually. The CDC has made no recommendation as to the type of test that should be performed. Both the enzyme-linked immunosorbent assay and the rapid HIV test would be acceptable, for example. “Depending on the nature of the test, we anticipate that in general, an HIV-negative test would cost in the range $8,” Dr. Bernard Branson said at the briefing. “Because you have to do confirmation and longer counseling for the [much smaller] number of people who will test positive, the cost can be as high as $80.” Dr. Branson, who is associate director for Laboratory Diagnostics at the CDC’s Division of HIV/AIDS Prevention, said that many published cost-effectiveness studies suggest that the cost of HIV screening is comparable with other common health screenings, such as those for breast cancer and hypertension. These studies suggest that routine screening would cost about $15,000 per quality-adjusted life year. ■

Spread Bacteria
BY BRUCE JANCIN

Denver Bureau

L I S B O N — The dispensers of alcoholbased disinfectant for hand washing that are ubiquitous in hospitals and physicians’ offices are often contaminated with bacteria, including potential pathogens, Dr. Kiran Mangalpally cautioned at the 12th International Congress on Infectious Diseases. He cultured the push bars of 44 such dispensers at Mount Vernon (N.Y.) Hospital, where he is a resident in internal medicine. Of the 44 dispensers, 35 (80%), proved culture positive. The push bars are activated by pressure applied by the palm or fingers, which releases a squirt of hand rinse or foam. But the disinfectant does not reach the push bar itself. The testing showed that 29 of the push bars grew coagulase-negative staphylococci and 4 grew Staphylococcus aureus, including 2 that yielded methicillin-resistant S. aureus. Another two push bars grew nonstaphylococcal bacteria. For comparison, Dr. Mangalpally also cultured 11 doorknobs from hospital bathrooms, and found that 9 were culture positive; all of those grew only coagulase-negative staphylococci. “This is one of those simple things we don’t think about much,” the physician noted in an interview at the congress sponsored by the International Society for Infectious Diseases. Alternatives to push bar–operated dispensers that would reduce the potential for infection are touch-free dispensers operated by foot pump, electronic sensor, or voice activation technology. These devices are commercially available, he noted. Dr. Mangalpally said he has shared his study findings with hospital administrators but is unsure if they will switch to the hands-free technology, which is more costly than what is currently being used. ■

Flu Vaccine to Be Shipped Earlier And in Greater Amounts This Year
akers of influenza vaccine will produce and distribute 100 million doses of the agent by early January—more than ever before and nearly 25% more than were shipped last year—with most doses to arrive in October and November, according to the Centers for Disease Control and Prevention. Shipments already have begun, and all providers who have ordered vaccine will receive at least some doses by the end of October, the CDC said in a statement. “When and how much vaccine each health care provider or clinic receives depends on [whom] they ordered from and when they ordered,” cautioned Dr. Lance Rodewald, director of the agency’s immunization services division. “We expect that some ... may get or have more influenza vaccine than others in the first

Adacel Shortage Called Temporary; Boostrix Supply Still Adequate
temporary shortage in the supply of Adacel—the tetanus-diphtheriapertussis vaccine marketed by SanofiPasteur—is expected to last until the end of the year. Boostrix, the Tdap booster vaccine that is manufactured by GlaxoSmithKline, is in good supply, according to the Centers for Disease Control and Prevention. Adacel (Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccine Adsorbed) is indicated as a booster for adolescents and adults aged 11-64 years, while Boostrix is indicated for adolescents aged 10-18 years. For information about Adacel availability, call Sanofi-Pasteur at 800-VACCINE.

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month or so, but people will have plenty of opportunities to be vaccinated during October and November, as well as December or later,” he noted. Vaccine manufacturers shipped just over 81 million doses of vaccine last year, only 15 million of which had arrived by the end of last October, according to vaccine manufacturers. This year, however, around 75 million are expected to have arrived by that time. The CDC and the Food and Drug Administration have been working with vaccine makers to prevent a shortage of vaccine. According to the CDC, influenza incidence was low from October through early January last year but increased significantly in February and peaked in early March.
—John R. Bell

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The supply shortage of Adacel is expected to be resolved by the end of 2006, said Susan Watkins, a spokesperson for Sanofi-Pasteur. A new vaccine production facility in Toronto that will provide a sevenfold increase of the supply of vaccines with pertussis components was approved by the Food and Drug Administration in late August. It has already started to manufacture the DTaP vaccine Daptacel, and will begin producing Adacel next, she said.
—Elizabeth Mechcatie

Updates on the Adacel shortage will be provided on the CDC Web site at www.cdc.gov/nip/news/shortages/ default.htm.