FISH GUIDELINES FLOUNDER IN A SEA OF CONTROVERSY
Women who are trying to conceive, are pregnant or are breast-feeding should eat at least 12 ounces of ocean fish per week, “and can do so safely,” according to recommendations from an expert group on maternal nutrition working in partnership with the National Healthy Mothers,Healthy Babies Coalition.1 In thewake of federal government advisories about thepossible adverse effects of high levelsofmercury in some types of fish, many pregnant women have eliminated fish from their diet, but the nutrition group counsels that by doing so, they may be consuming inadequate quantities of essential omega-3 fatty acids. In a review of the literature, the group found evidence that pregnant women’s consumption of ocean fish that are high in these fats is associated with “advanced cognitive and motor skill development” in their children andwith reduced levels ofpretermlabor and postpartum depression. The group also found that the selenium in certain ocean fish may help prevent harmful effects of mercury exposure. However, some members of the coalition—the March of Dimes, several federal agencies and the American College ofObstetricians andGynecologists—have distanced themselves from the group’s recommendations, objecting to their “silence” about four types of fish that the government guidelines single out because of their high levels of mercury.2
1. National Healthy Mothers, Healthy Babies Coalition, For pregnant women, benefits of eating ocean fish outweigh concerns from trace levels of mercury, news release, Oct. 4, 2007, <http://www.hmhb.org/oceanfishpr.html>, accessed Oct. 11, 2007.
2. Weise E, Coalition splits over fish guidelines for pregnant women, USA Today, Oct. 10, 2007, <http://www.usatoday.com/news/health/2007-10-10-fish-guidelines_N.htm>, accessed Oct. 12, 2007.
A WAY TO SLOW HIV?
Some research conducted before highly active antiretroviral therapy (HAART) was available suggested that pregnancy could hasten the progression of HIV disease to AIDS, but a study of HIV-infected women attending a Nashville clinic from 1997 through 2004 suggests that in the HAART era, the opposite may be the case.1 Of the 759 women included, 71% were receiving HAART and 18% became pregnant at least once during the study period. Women who had a pregnancy were less sick at baseline than those who did not, and they were more likely to be receiving HAART. They also were less likely than those who had no pregnancies to develop AIDS or die during follow-up (8% vs. 24%). The investigators conclude that more research is needed on the mechanisms “by which pregnancy [may] impede HIV disease progression,” particularly “the interaction between [HAART] and the immunological changes that occur during pregnancy.”
1. Tai JH et al., Pregnancy and HIV disease progression during the era of highly active antiretroviral therapy, Journal of Infectious Diseases, 196(7):1044–1052.
PEDIATRICIANS NOW HAVE GUIDELINES ON HPV VACCINE
The American Academy of Pediatrics has issued a provisional statement recommending that pediatricians administer the human papillomavirus (HPV) vaccine to all 11- and 12-year-old girls, to girls as young as nine if they consider it necessary and to 13–26-year-olds who have not received the full vaccine series (even if they are sexually experienced).1 The recommendations also note that the HPV vaccine does not obviate the need for cervical cancer screening or for counseling about STDprevention and “healthy choices about sexual activity.” The statement further says that the vaccine is not recommended formales, but that its use for males will be considered once the results of safety and efficacy studies have been analyzed. A full policy statement on HPV immunization for females is in preparation.
1. Committee on Infectious Diseases, American Academy of Pediatrics, Prevention of human papillomavirus infection: provisional recommendations for immunization of girls and women with quadrivalent human papillomavirus vaccine, Pediatrics, 2007, 120(3):666–668.
Clinical trials aimed at preventing STDs by targeting risky sexual behavior largely exclude individuals older than 50, even though these “older” adults are increasingly at risk of acquiring HIV and often do not engage in protective behavior.1 In a review of the literature, researchers found 143 relevant studies published in English-language journals from 1994 through 2004. Some 73% of these trials excluded persons older than 50, and 89% excluded those older than 65; none were limited to older adults. Despite a rapidly growing incidence of AIDS among people older than 50, their level of inclusion in STD prevention trials did not change over the decade. “Exclusion from these clinical trials,” the investigators comment, “has the effect of suggesting to physicians and the public that older individuals are not susceptible to STDs.” Remedying this situation, they conclude, will require the participation of researchers, funders, advocacy groups, and journal editors and reviewers.
1. Levy BR et al., Older persons’ exclusion from sexually transmitted disease risk-reduction clinical trials, Sexually Transmitted Diseases, 2007, 34(8):541–544.
EXPANDING THE PROVIDER BASE
Even in settings where surgical abortion is not offered, providers can expand the availability of abortion by offering medical procedures.1 Between 2002 and 2005, a total of 220 women sought pregnancy options counseling at three clinics in New Mexico that offer medical, but not surgical, abortion. (Patients who opt for surgical abortions are referred to nearby clinics.) Most were no more than nine weeks pregnant and were therefore eligible to undergo medical abortion; 85% of eligible women chose to have the procedure. Virtually all of those who had medical abortions (96%) made at least one followup visit to the clinic, and 98% of this group had complete abortions. Researchers speculate that the high proportion of women choosing medical abortion was attributable to “convenience, self-selection and physician counseling,” but they caution physicians “not to let convenience outweigh other factors” that may be important in a woman’s abortion decision.
1. Leeman L et al., Can mifepristone medication abortion be successfully integrated into medical practices that do not offer surgical abortion? Contraception, 2007, 76(2):96–100.
AWARENESS IS NOT ENOUGH
U.S. women’s generally high awareness of breast cancer “is not translating into knowledge,” according to results of a survey conducted in August among about 1,000 women aged 18 or older.1 Three-quarters of respondents reported that they were knowledgeable about breast cancer, and three in five said that they had recently read or heard something about it. However, 56% mistakenly believed that breast cancer occurs predominantly among women with a family history of or a genetic predisposition to the disease, and 78% thought that a diet rich in fruits and vegetables can help prevent it, although the most recent research indicates otherwise. Four in 10 respondents emphasized the importance of breast self-examination, apparently unaware that its value is questionable. On the other hand, 80% knew that the use of hormone replacement therapy increases the risk of breast cancer.
1. National Breast Cancer Coalition, National Breast Cancer Coalition survey reveals that heightened breast cancer awareness has insufficient impact on knowledge, news release, Oct. 1, 2007, <http://www.natlbcc.org/bin/index.asp?strid=985&btnid=2&depid=20>, accessed Oct. 11, 2007.
PUBLIC HEALTH VS. THE LAW
The majority of states have laws that prevent the kind of routine testing for HIV that the Centers for Disease Control and Prevention (CDC) recommended in 2006 to help reduce the number of people who are infected and unaware of it.1 The CDC specifically recommends eliminating consent requirements and pretest counseling, and instead calls for providers to tell all patients aged 13–64 that they will be tested for HIVunless they choose not to be. However, the states have the last word, and researchers reviewing current statutes and regulations found that 14 states require written informed consent for HIV testing, and 19 require oral consent; 11 require pretest counseling, and 24 specify topics to be covered during the informed consent process or pretest counseling. Moreover, states that have amended relevant laws since 2004 have generally not made it any easier to implement routine HIV testing and in some cases have made it more difficult. As the researchers acknowledge, the CDC recommendations have not met the needs of all stakeholders; developing a “generally acceptable and implementable” policy on HIV testing will require further discussion among “public health and medical professionals, HIV advocates and legislators.”
1. Wolf LE, Donoghoe A and Lane T, Implementing routine HIV testing: the role of state law, PloS ONE, 2007, 2(10):e1005.
SEIZE THE MOMENT TO SCREEN
Brief, problem-focused doctor visits, a mainstay of many adolescents’ health care, may present opportunities to screen teenagers for chlamydia infection, according to results of a survey conducted in four pediatric clinics.1 In interviews immediately following an urgent care visit, 84% of participants, who were aged 13–18, indicated that discussion of sexual health would be “okay” during such a visit; 80% said that providing a urine sample for testing would be okay. The odds that teenagers gave these responses were elevated if they felt that their doctor knows howto talk to them(odds ratios, 9.0 and 3.7, respectively) and listens carefully to them (14.3 and 3.6); acceptability of sexual health discussion alsowas associated with teenagers’ feeling that their doctor assures them of the confidentiality of their discussions (2.7). As the researchers comment, high rates of chlamydia infection among teenagers demand “an expansion of… screening efforts beyond traditional boundaries,” and these findings suggest that urgent care visits may be a “teen-acceptable” alternative.
1. Miller CA et al., Chlamydial screening in urgent care visits: adolescent-reported acceptability associated with adolescent perception of clinician communication, Archives of Pediatrics and Adolescent Medicine, 2007, 161(8):777–782.
NOT WHAT THE PLAN PLANNED
Although Medicaid managed care was intended to improve access to health care for low-income individuals, an analysis of California’s vital statistics for 1990–2000 suggests that it might be having the opposite effect.1 In counties that instituted Medicaid managed care, the probability that disadvantaged women began receiving prenatal care in the first trimester declined by 4–6 percentage points after the new system was introduced. Depending on the type of plan, the availability of high-level neonatal intensive care towomen covered by Medicaid either increased or remained unchanged; however, disadvantaged women in some counties increasingly went to poorquality hospitals, as indicated by neonatal mortality rates. The probability of cesarean delivery was stable, but the likelihood of poor birth outcomes—low birth weight, short gestation and neonatal deaths—increased after Medicaid managed care was implemented. According to the analysts, the findings may reflect that “the plans’ incentive to provide preventive care was effectively removed,” and “as other vulnerable populations…are shifted into managed care, it will be important to determine whether plans have sufficient incentive to safeguard the health of their enrollees.”
1. Aizer A, Currie J and Moretti E, Does managed care hurt health? evidence from Medicaid mothers, Review of Economics and Statistics, 2007, 89(3):385–399.