Meningococcal Vaccine Not Routine 2-10yrs Child

MMWR Morbid Mortal Wkly Rep. 2008;57(17):462-465.

Clinical Context

The MCV4 (Menactra; Sanofi-Pasteur) was approved by the US Food and Drug Administration on October 17, 2007, for use in children aged 2 to 10 years, adding to the existing approval for use in persons aged 11 to 55 years. MCV4 licensure was based on clinical trials in which the safety and immunogenicity of MCV4 was compared with the MPSV4 and was found to be safe and noninferior to the MPSV4 for all serogroups.

From June 2007 to February 2008, the ACIP Meningococcal Vaccine Workgroup considered use of MCV4 in children aged 2 to 10 years. They reviewed data on MCV4 immunogenicity and safety in this age group, the epidemiology and burden of meningococcal disease, the cost-effectiveness of different vaccination strategies, and the programmatic implications. Based on this review, the expert opinion of workgroup members, and feedback from partner organizations, the ACIP decided at its February 2008 meeting not to routinely vaccinate children aged 2 to 10 years.

Study Highlights

• ACIP evaluated data and concluded that evidence was insufficient to determine that 1 dose of MCV4 administered at age 2 years would protect against meningococcal disease through late adolescence and college entry.
• Serum bactericidal activity among children aged 2 to 3 years who received MCV4 was lower vs children aged 4 to 10 years.
• ACIP also reviewed the burden of meningococcal disease among children aged 2 to 10 years.
• Between 1998 and 2007 in the United States, overall rates of meningococcal disease were lower in children aged 2 to 10 years vs infants younger than 2 years and adolescents aged 11 to 19 years.
• Of cases in children aged 2 to 10 years, 41% occurred among children aged 2 to 3 years.
• Among cases that occurred in children 2 to 10 years old, 59% were caused by serogroups contained in MCV4 (A, C, Y, and W-135) vs 77% of cases among those 11 to 19 years old.
• A cost-effectiveness analysis determined that vaccinating children aged 2 years was less cost effective than vaccinating children aged 11 years.
• As of February 2008, the ACIP does not recommend routine vaccination of children aged 2 to 10 years against meningococcal disease unless the child is at increased risk.
• ACIP continues to recommend vaccination for children aged 2 to 10 years who are at increased risk for meningococcal disease.
• Risk factors for meningococcal disease include travel to or residence in countries where meningococcal disease is hyperendemic or epidemic, terminal complement deficiencies, and anatomic or functional asplenia.
• Using clinical judgment on a case-by-case basis, clinicians may also decide to vaccinate children aged 2 to 10 years who are infected with HIV.
• MCV4 is preferred to MPSV4 for children aged 2 to 10 years at increased risk, for control of meningococcal disease outbreaks, and when clinicians or parents decide on meningococcal vaccination for other children aged 2 to 10 years.
• Children aged 2 to 10 years who have received MPSV4 and who are still at increased risk for meningococcal disease should be vaccinated with MCV4 3 years after receiving MPSV4.
• Children who last received MPSV4 less than 3 years before and who are still at increased risk for meningococcal disease should receive MCV4 vaccination as soon as possible.
• Recommendations for use of MCV4 in persons aged 11 to 55 years remain unchanged from earlier published guidelines.
• ACIP continues to recommend routine vaccination against meningococcal disease for all persons aged 11 to 18 years.
• ACIP recommends vaccination against meningococcal disease for persons aged 2 to 55 years who are at increased risk for meningococcal disease.
• Children at increased risk for meningococcal disease throughout their lifetime will most likely need subsequent doses of MCV4, with specific recommendations anticipated based on ongoing ACIP monitoring on duration of protection.
• A history of GBS is a precaution to MCV4 vaccination because these individuals might be at increased risk for GBS after MCV4 vaccination.

Pearls for Practice

• As of February 2008, the ACIP does not recommend routine vaccination of children aged 2 to 10 years against meningococcal disease unless the child is at increased risk because of travel to or residence in countries where meningococcal disease is hyperendemic or epidemic, terminal complement deficiencies, or anatomic or functional asplenia.
• Recommendations for use of MCV4 in persons aged 11 to 55 years remain unchanged from earlier published guidelines. ACIP continues to recommend routine vaccination against meningococcal disease for all persons aged 11 to 18 years. ACIP recommends vaccination against meningococcal disease for persons aged 2 to 55 years who are at increased risk for meningococcal disease.

Smoking Increase Death Risks

Vascular Benefits of Stopping Smoking Are Rapid

News Author: Lisa Nainggolan Medscape
CME Author: Charles Vega, MD

Smoking is clearly linked with an increased risk of mortality, and a previous report on the Nurses' Health Study by Kawachi and colleagues, published in the November 15, 1993, issue of Annals of Internal Medicine, described this risk in detail. Researchers demonstrated that the overall risk of mortality among smokers vs never smokers was 1.87, and the risk of former smokers vs never smokers was significantly elevated at 1.29. Participants who initiated smoking before the age of 15 years had the highest risks for total mortality and cardiovascular disease mortality, but these risks were attenuated to levels similar to never smokers after 10 to 14 years of abstinence from smoking.

The current report from the Nurses' Health Study provides greater detail with regard to cancer mortality risks associated with cigarette smoking in women.

Study Highlights

• The Nurses' Health Study began following 121,700 female nurses in the United States in 1976. Subjects have provided health information every 2 years since initiation of the study, including data regarding cigarette use. Women with a prior history of cancer were excluded from the current study.
• In the current study, researchers focused on reports of overall mortality as well as specific cancer, vascular, and respiratory causes of mortality from 1980 forward. Never smokers were used as the reference group, and the risk of study outcomes associated with smoking was adjusted for body mass index as well as disease and lifestyle factors.
• In 1980, 28% of the study cohort reported current smoking, and 26% were former smokers. The mean age at smoking initiation was 19 years.
• Current smokers had lower body mass index values and slightly less hypertension and also exercised less compared with never or former smokers.
• 12,483 deaths occurred in the study group, 28.9% and 35.2% of which occurred among current and former smokers, respectively. Only 8% of subjects alive in 2002 were current smokers.
• Current smokers experienced a HR of 2.81 for total mortality compared with never smokers, and they were also at higher risk for all major cause-specific mortality.
• Current smokers had a higher risk of death associated with all smoking-related cancers vs never smokers. These cancer sites included bladder, cervix, esophagus, lip and mouth, pharynx, pancreas, and stomach. Smokers were also at higher risk of mortality resulting from acute myeloid leukemia.
• Current smokers also had a significant increased risk of mortality resulting from colorectal cancer vs never smokers (HR = 1.63), but the effect of current smoking on the risk of ovarian cancer mortality was not significant. These same trends were evident among former smokers.
• Overall, 64% of deaths among current smokers were attributable to cigarette smoking.
• Earlier initiation of smoking was associated with a higher risk of death, particularly for death related to respiratory disease or cancer.
• The risk of death decreased by 13% within 5 years of quitting cigarettes, and this risk was further attenuated to levels comparable with never smokers at 20 years after quitting.
• The risk of death resulting from vascular disease declined more rapidly compared with other mortality risks following smoking cessation, with 61% of the full potential benefit for coronary heart disease mortality accrued in the first 5 years after quitting.
• Approximately 28% of deaths among former smokers were attributable to cigarette smoking.

Pearls for Practice

• A previous report from the Nurses' Health Study demonstrated that both current and former smokers had an increased risk of mortality compared with never smokers, but this risk was significantly attenuated after 10 to 14 years of abstinence from smoking. Women who began smoking prior to 15 years of age experienced the highest risk of mortality.
• In the current study, smoking increased the risk of death due to cancers of the cervix, colon and rectum, and stomach. However, the risk of ovarian cancer mortality was not significantly increased with smoking.