XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

Considerable advances have occurred in recent years in the scientific knowledge of the benefits of breastfeeding, the mechanisms underlying these benefits, and in the clinical management of breastfeeding. This policy statement on breastfeeding replaces the 1997 policy statement of the American Academy of Pediatrics and reflects this newer knowledge and the supporting publications. The benefits of breastfeeding for the infant, the mother, and the community are summarized, and recommendations to guide the pediatrician and other health care professionals in assisting mothers in the initiation and maintenance of breastfeeding for healthy term infants and high-risk infants are presented. The policy statement delineates various ways in which pediatricians can promote, protect, and support breastfeeding not only in their individual practices but also in the hospital, medical school, community, and nation.

/pdf/breastfeeding-and-the-use-of-human-milk-2m74a0njro.pdf

Breastfeeding and the Use of Human Milk

Lionel A. Mandell, Richard G. Wunderink, Antonio Anzueto, John G. Bartlett, G. Douglas Campbell, Nathan C. Dean, Scott F. Dowell, Thomas M. File, Jr. Daniel M. Musher, Michael S. Niederman, Antonio Torres, and Cynthia G. Whitney McMaster University Medical School, Hamilton, Ontario, Canada; Northwestern University Feinberg School of Medicine, Chicago, Illinois; University of Texas Health Science Center and South Texas Veterans Health Care System, San Antonio, and Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas; Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Mississippi School of Medicine, Jackson; Division of Pulmonary and Critical Care Medicine, LDS Hospital, and University of Utah, Salt Lake City, Utah; Centers for Disease Control and Prevention, Atlanta, Georgia; Northeastern Ohio Universities College of Medicine, Rootstown, and Summa Health System, Akron, Ohio; State University of New York at Stony Brook, Stony Brook, and Department of Medicine, Winthrop University Hospital, Mineola, New York; and Cap de Servei de Pneumologia i Allergia Respiratoria, Institut Clinic del Torax, Hospital Clinic de Barcelona, Facultat de Medicina, Universitat de Barcelona, Institut d’Investigacions Biomediques August Pi i Sunyer, CIBER CB06/06/0028, Barcelona, Spain.

/pdf/infectious-diseases-society-of-america-american-thoracic-1cn65eiqga.pdf

Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults

This report updates the 2002 recommendations by the Advisory Committee on Immunization Practices (ACIP) on the use of influenza vaccine and antiviral agents (CDC. Prevention and Control of Influenza: Recommendations of the Advisory Committee on Immunization Practices [ACIP]. MMWR 2002;51 [No. RR-3]:1-31). The 2003 recommendations include new or updated information regarding 1) the timing of influenza vaccination by age and risk group; 2) influenza vaccine for children aged 6-23 months; 3) the 2003-2004 trivalent inactivated vaccine virus strains: A/Moscow/10/99 (H3N2)-like, A/New Caledonia/20/99 (H1N1)-like, and B/Hong Kong/330/2001-like antigens (for the A/Moscow/10/99 [H3N2]-like antigen, manufacturers will use the antigenically equivalent A/Panama/2007/99 [H3N2] virus, and for the B/Hong Kong/330/2001-like antigen, manufacturers will use either B/Hong Kong/330/2001 or the antigenically equivalent B/Hong Kong/1434/2002); 4) availability of certain influenza vaccine doses with reduced thimerosal content, including single 0.25 mL-dose syringes; and 5) manufacturers of influenza vaccine for the U.S. market. Although the optimal time to vaccinate against influenza is October and November, vaccination in December and later continues to be strongly recommended A link to this report and other information regarding influenza can be accessed at http://www.cdc.gov/ncidod/diseases/flu/fluvirus.htm.

https://stacks.cdc.gov/view/cdc/6625/cdc_6625_DS1.pdf

Prevention and control of influenza : recommendations of the Advisory Committee on Immunization Practices (ACIP)

The MMWR series of publications is published by the Office of Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services, Atlanta, GA 30333.

/pdf/sexually-transmitted-diseases-treatment-guidelines-4zaqk3joit.pdf

Sexually transmitted diseases treatment guidelines.

Access to sufficient safe food is a basic requirement for human health. Ensuring food safety and security in a highly globalized world presents increasingly difficult, and often under-appreciated challenges, for governments, commercial organizations and individuals alike.1,2

The risks of unsafe food are substantial, but can be difficult to quantify. Diarrhoeal diseases – both foodborne and waterborne – kill an estimated two million people annually, including many children in developing countries. Food contaminants, such as harmful parasites, bacteria, viruses, prions, chemical or radioactive substances, cause more than 200 diseases – ranging from infectious diseases to cancers.3

In parallel with the increasing size of the world population, consumer demand for a wider variety of foods is growing, entailing a longer and more complex food-chain. In this context, for the World Health Day, on 7 April 2015, the World Health Organization (WHO) has chosen to focus on food safety. Today, food ingredients often come from multiple countries, with each item having travelled thousands of kilometres from a field, farm or factory. Contamination at one end of the food-chain can affect populations on the other side of the world. Given the interaction of multiple actors separated by vast distances and potentially delayed impacts, multisectoral and international cooperation is essential. Food safety needs strengthening in many countries – but no country can do this alone.

World Health Day is one of a series of actions that WHO is taking to raise awareness about the food safety agenda and to galvanize action. WHO, in collaboration with the United Nations Food and Agriculture Organization (FAO), has had a central international role in developing guidelines to strengthen and harmonize food systems, in particular through the jointly managed Codex Alimentarius Commission. Codex standards have become the de facto international standards for food safety. WHO and FAO also manage the International Food Safety Authorities Network (INFOSAN), which provides timely information during food safety emergencies4 and assists countries in building strong systems to prevent such incidents. WHO has also established the Global Foodborne Infections Network5 to promote integrated, laboratory-based surveillance and foster multisectoral collaboration.

In 2010, the 63rd World Health Assembly adopted a resolution to advance food safety.6 As a result, a strategic plan was developed which requires WHO to: (i) provide the evidence base for measures to decrease foodborne health risks along the entire food-chain; (ii) improve international and national cross-sectoral collaboration, including communication and advocacy; and (iii) provide leadership and assist in the development and strengthening of risk-based, integrated national systems for food safety.7 In November 2014, the second International Conference on Nutrition8 reaffirmed the right for everyone to have access to safe, sufficient and nutritious food; the need to strengthen food production and distribution systems and the importance of fair trade practices. Recently, WHO has also provided guidance on food safety for food producers, transporters and consumers.9

There is a need to refocus attention and to re-energize commitments on food safety – especially coordinated and cooperative actions and communications across borders. Better data and methods are needed to estimate the health impact of foodborne diseases and to guide response and prevention actions. This year, WHO will release the first comprehensive estimates of the global burden of death and illness caused by foodborne diseases.10 More investment is needed in national food safety systems, reflecting the importance of food safety as a public health priority. Governments have several key roles to play. In addition to setting policies, they are critical for establishing and implementing the national food safety systems within which food producers and suppliers must operate. Consumers can stay informed, for example, through self-education and by reading labels on packaging.

In the 21st century, collaboration is vital to achieving safe food-chains that cross national borders. This is why WHO works closely with FAO, the World Organization for Animal Health (OIE) and other international organizations to ensure food is safe to eat. This year’s World Health Day is an opportunity to strengthen food safety across all borders and stakeholders.

/pdf/food-safety-in-a-globalized-world-3xy88aknp0.pdf

Food safety in a globalized world

PROBLEM/CONDITION
Influenza epidemics occur nearly every year during the winter months and are responsible for substantial morbidity and mortality in the United States, including an average of approximately 114,000 hospitalizations and 20,000 deaths per year.


REPORTING PERIOD
This report summarizes U.S. influenza surveillance data from October 1994 through May 1997, from both active and passive surveillance systems.


DESCRIPTION OF SYSTEM
During the period covered, CDC received weekly reports from October through May from a) state and territorial epidemiologists on estimates of local influenza activity, b) approximately 140 sentinel physicians on their total number of patient visits and the number of cases of influenza-like illness (ILI), and c) approximately 70 World Health Organization (WHO) collaborating laboratories in the United States on weekly influenza virus isolations. WHO collaborating laboratories also submitted influenza isolates to CDC for antigenic analysis. Throughout the year, vital statistics offices in 121 cities reported deaths related to pneumonia and influenza (P&I) weekly, providing a measure of the impact of influenza on mortality.


RESULTS
During the 1994-95 influenza season, 25 state epidemiologists reported regional or widespread activity at the peak of the season. Cases of ILI reported by sentinel physicians exceeded baseline levels for 4 weeks, peaking at 5%. Influenza A(H3N2) was the most frequently isolated influenza virus type/subtype. The longest period of sustained excess mortality was 5 consecutive weeks, when the percentage of deaths attributed to P&I exceeded the epidemic threshold, peaking at 7.6%. During the 1995-96 season, 33 state epidemiologists reported regional or widespread activity at the peak of the season. ILI cases exceeded baseline levels for 5 weeks, peaking at 7%. Influenza A(H1N1) viruses predominated, although influenza A(H3N2) and influenza B viruses also were identified throughout the United States. P&I mortality exceeded the epidemic threshold for 6 consecutive weeks, peaking at 8.2%. The 1996-97 season was the most severe of the three seasons summarized in this report. Thirty-nine state epidemiologists reported regional or widespread activity at the peak of the season. ILI reports exceeded baseline levels for 5 consecutive weeks, peaking at 7%. The proportion of respiratory specimens positive for influenza peaked at 34%, with influenza A(H3N2) viruses predominating. Influenza B viruses were identified throughout the United States, but only one influenza A(H1N1) virus isolate was reported overall. The proportion of deaths attributed to P&I exceeded the epidemic threshold for 10 consecutive weeks, peaking at 9.1%.


INTERPRETATION
Influenza A(H1N1), A(H3N2), and B viruses circulated during 1994-1997. Local surveillance data are important because of geographic and temporal differences in the circulation of influenza types/subtypes.


PUBLIC HEALTH ACTIONS
CDC conducts active national surveillance annually from October through May for influenza to detect the emergence and spread of influenza virus variants and monitor the impact of influenza-related morbidity and mortality. Surveillance data are provided weekly throughout the influenza season to public health officials, WHO, and health-care providers and can be used to guide prevention and control activities, vaccine strain selection, and patient care.

/pdf/surveillance-for-lyme-disease-united-states-1992-1998-and-2ixcwkk5kv.pdf

Surveillance for lyme disease--United States, 1992-1998 and Surveillance for influenza--United States, 1994-95, 1995-96, and 1996-97 seasons

PROBLEM/CONDITION CDC conducts active surveillance annually from October through May on the emergence and spread of influenza virus variants and the impact of influenza-related morbidity and mortality. Influenza activity is also monitored throughout the year by passive surveillance. REPORTING PERIOD COVERED This report summarizes U.S. influenza surveillance from October 1992 through May 1994. DESCRIPTION OF SYSTEM Influenza surveillance comprises four components, three of which provide weekly data from October through May: a) state and territorial epidemiologists provide estimates of local influenza activity; b) approximately 140 sentinel physicians report their total number of patient visits and the number of cases of influenza-like illness; and c) approximately 70 collaborating laboratories of the World Health Organization (WHO) report weekly influenza virus isolations and submit selected influenza isolates to CDC for antigenic analysis. Throughout the year, vital statistics offices of 121 cities report deaths related to pneumonia and influenza (PI influenza A(H3N2) viruses predominated. INTERPRETATION The change in predominance from influenza B to influenza A in the spring of 1993 emphasizes the importance of annual influenza surveillance. Although influenza vaccine is effective against both influenza A and B, the antiviral drugs amantadine and rimantadine are effective only against influenza A. Outbreaks during the summer of 1993 emphasize that influenza should be considered a possible cause of respiratory infections during summer and early autumn. ACTIONS TAKEN Surveillance data were provided weekly throughout the influenza season to public health officials, WHO, and health-care providers.

Influenza Surveillance - United States, 1992-93 and 1993-94

Detection of HTLV-II in breastmilk of HTLV-II infected mothers

OBJECTIVE: To evaluate the use of influenza vaccine, rapid influenza testing, and influenza antiviral medication in nursing homes in the US to prevent and control outbreaks.



METHODS: Survey questionnaires were sent to 1017 randomly selected nursing homes in nine states. Information was collected on influenza prevention, detection and control practices, and on outbreaks during three influenza seasons (1995–1998).



RESULTS: The survey response rate was 78%. Influenza vaccine was offered to residents and staff by 99% and 86%, respectively, of nursing homes. Among nursing homes offering the influenza vaccine, the average vaccination rate was 83% for residents and 46% for staff. Sixty-seven percent of the nursing homes reported having access to laboratories with rapid antigen testing capabilities, and 19% reported having a written policy for the use of influenza antiviral medications for outbreak control. Nursing homes from New York, where organized education programs on influenza detection and control have been conducted for many years, were more likely to have reported a suspected or laboratory-confirmed influenza outbreak (51% vs 10%, P = .01), to have access to rapid antigen testing for influenza (92% vs 63%, P = .01), and to use antivirals for prophylaxis and treatment of influenza A for their nursing home residents (94% vs 55%, P = .01) compared with nursing homes from the other eight states.



CONCLUSIONS: Influenza outbreaks among nursing home residents can lead to substantial morbidity and mortality when prevention measures are not rapidly instituted. However, many nursing homes in this survey were neither prepared to detect nor to control influenza A outbreaks. Targeted, sustained educational efforts can improve the detection and control of outbreaks in nursing homes.

Keiji Fukuda

Papers

Food safety in a globalized world

Surveillance for lyme disease--United States, 1992-1998 and Surveillance for influenza--United States, 1994-95, 1995-96, and 1996-97 seasons

Influenza Surveillance - United States, 1992-93 and 1993-94

Detection of HTLV-II in breastmilk of HTLV-II infected mothers

Influenza outbreak detection and control measures in nursing homes in the United States.