O c t o b e r 1 5 , 2 0 0 6 • w w w. i n t e r n a l m e d i c i n e n e w s .
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CDC Recommends Routine HIV Hand Washing
Screening Regardless of Patient Risk Dispensers Can
BY ROBERT FINN
San Francisco Bureau
T
he Centers for Disease Control
and Prevention has recommend-
ed 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 re-
main 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 ul-
timately no person in the United States
should acquire HIV infection.”
Studies show that almost 40% of indi-
viduals diagnosed with HIV receive that
diagnosis within a year of the infection
progressing to AIDS, and presumably
about 10 years after they were initially in-
fected. Often, this is too late for them to
fully benefit from treatment.
Furthermore, it is estimated that peo-
ple who are unaware of their infection ac-
count for 50%-70% of new sexually trans-
mitted HIV infections. People who are
aware of their HIV infections typically
take steps to protect their partners.
The recommendations, slated for pub-
lication 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 hospi-
tal emergency departments, urgent care
clinics, inpatient services, substance
abuse treatment clinics, public health
Flu Vaccine to Be Shipped Earlier
And in Greater Amounts This Year
M akers of influenza vaccine will pro-
duce and distribute 100 million dos-
es 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 Con-
trol 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 de-
pends on [whom] they ordered from and
when they ordered,” cautioned Dr. Lance
Rodewald, director of the agency’s im-
munization services division. “We expect
that some ... may get or have more in-
fluenza vaccine than others in the first
News
clinics, community clinics, correctional
health care facilities, and primary care
settings.
The new recommendations do not ap-
ply to nonclinical settings, such as com-
munity 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 preva-
lence, and many providers report that
they do not have time to conduct risk as-
sessments.
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 coun-
seling 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 preg-
nant women. Existing recommenda-
tions for screening in this population
have been remarkably successful in pre-
venting mother-to-child HIV transmis-
sion: The number of infants born with
HIV has declined from about 1,650 in
month or so, but people will have plenty
of opportunities to be vaccinated during
October and November, as well as De-
cember 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 man-
ufacturers. This year, however, around 75
million are expected to have arrived by
that time.
The CDC and the Food and Drug Ad-
ministration have been working with vac-
cine makers to prevent a shortage of vac-
cine. According to the CDC, influenza
incidence was low from October through
early January last year but increased sig-
nificantly in February and peaked in ear-
ly March.
—John R. Bell
9
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. Further-
more, 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 im-
mediately, but the agency plans to issue
additional guidance for health care
providers in early 2007 that will provide
examples of model approaches and prac-
tical 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 recommenda-
tion as to the type of test that should be
performed. Both the enzyme-linked im-
munosorbent 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-neg-
ative 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 com-
mon 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. ■ ly than what is currently being used. ■
Adacel Shortage Called Temporary;
Boostrix Supply Still Adequate
A temporary shortage in the supply
of Adacel—the tetanus-diphtheria-
pertussis vaccine marketed by Sanofi-
Pasteur—is expected to last until the
end of the year.
Boostrix, the Tdap booster vaccine
that is manufactured by GlaxoSmith-
Kline, is in good supply, according to
the Centers for Disease Control and
Prevention.
Adacel (Tetanus Toxoid, Reduced
Diphtheria Toxoid and Acellular Per-
tussis Vaccine Adsorbed) is indicated as
a booster for adolescents and adults
aged 11-64 years, while Boostrix is indi-
cated for adolescents aged 10-18 years.
For information about Adacel availabil-
ity, call Sanofi-Pasteur at 800-VACCINE.
Spread Bacteria
BY BRUCE JANCIN
Denver Bureau
L I S B O N — The dispensers of alcohol-
based disinfectant for hand washing that are
ubiquitous in hospitals and physicians’ of-
fices are often contaminated with bacteria,
including potential pathogens, Dr. Kiran
Mangalpally cautioned at the 12th Inter-
national Congress on Infectious Diseases.
He cultured the push bars of 44 such
dispensers at Mount Vernon (N.Y.) Hos-
pital, 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 staphylo-
cocci and 4 grew Staphylococcus aureus, in-
cluding 2 that yielded methicillin-resistant
S. aureus. Another two push bars grew
nonstaphylococcal bacteria.
For comparison, Dr. Mangalpally also
cultured 11 doorknobs from hospital bath-
rooms, and found that 9 were culture pos-
itive; all of those grew only coagulase-neg-
ative 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 dis-
pensers that would reduce the potential
for infection are touch-free dispensers op-
erated 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 cost-
The supply shortage of Adacel is ex-
pected to be resolved by the end of
2006, said Susan Watkins, a spokesper-
son for Sanofi-Pasteur. A new vaccine
production facility in Toronto that will
provide a sevenfold increase of the sup-
ply of vaccines with pertussis compo-
nents 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.