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AIDS threatens the world's children, Preventing the complications of childhood diabetes, On the vaccine front; Eye on Washington
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The 13th International Conference on AIDS convened in Durban, South Africa, on July 9, and the news for the world's children was not good. The situation in sub-Saharan Africa, according to the latest report from UNAIDS, is truly devastating: The UN agency estimates that 1 million children there are currently infected with HIV/AIDS (See map) and 13.2 million children have been orphaned (death of mother or both parents before the age of 15) by the epidemic. And there is no end in sight.
Three issues stand out:
Maternal-infant transmission. Five years ago, when tests of a short regimen of AZT for HIVinfected pregnant women and their newborns showed substantial reductions in vertical transmission of the virus, it seemed possible that the childrenat leastcould be saved from the ravages of AIDS. The bad news is that although the newborns were indeed protected, they are acquiring the infection after birth through breast milk. Since safe alternatives to breast milk are unaffordable and often culturally unacceptable to African women, the hoped-for gains from the AZT regimen have not materialized. The next order of business will be to find ways of providing safe alternatives to breastfeeding and educating the population to use theman enormously daunting task.
The high cost of antiretroviral drugs. Until very recently, it has been axiomatic that AIDS therapiesdespite their considerable victories in other parts of the worldare beyond the reach of poor nations. They simply cost too much, and that seemed to be that. Prevention was the only feasible approach. But there are signs that this log jam is breaking. African nations (with some encouragement from the White House and the World Health Organization) announced plans to manufacture AIDS drugs themselves, even if that meant defying the manufacturers' patent protection. At the same time, five of the major AIDS drugs manufacturers announced they were discussing cutting prices drastically, possibly by as much as 80%, for poor nations. Glaxo Wellcome, the only company to get specific, said it would cut the price of Combivir, its AZT and 3TC combination, from the global average of $16 a pill to $2. While there is serious question that many African countries could afford to buy and distribute the medications even at reduced prices, these actions may be the beginning of a trend toward affordable drug prices in the Third World.
Prevention can work. According to a report from Dr. Peter Piot, who heads the UNAIDS agency, educational efforts to curtail risky behavior in certain African countries, including Uganda, Zambia, and Senegal, have had considerable success. More young people in these countries are delaying first sexual intercourse, decreasing the number of partners, and using condoms, and the impact of these behavioral changes can be seen in declining rates of infection. Even in South Africa, where HIV infection is rampant and social mores have militated against frank discussion of sexual behavior, a new ad campaign of startling frankness is appearing on billboards throughout the country.
Calling type 2 diabetes in children "an emerging epidemic," the American Diabetes Association has issued a consensus statement on testing and treatment. According to the consensus panel, diabetes testing should be done every two years starting at age 10 in children who are overweight or have other risk factors such as a family history of diabetes or signs of insulin resistance. Treatment in most cases should include oral medication, self-management education, referral to a dietitian experienced in managing children with diabetes, and daily physical exercise. Following these recommendations, says Arlan Rosenbloom, MD, chairperson of the consensus panel, will "help diagnose, treat, and ultimately lower the risk of complications of this disease in children and adolescents."
Data for childhood immunization coverage rates for 1999 are in hand, and they are the highest ever recorded. Overall, 80% of preschool children are fully immunized. In terms of individual vaccines, 93.5% of toddlers are covered for Haemophilus influenzae type b (Hib); 95.9% for three doses of diphtheria, tetanus, and pertussis (DTaP); 88.1% for three doses of hepatitis B; and 59.4% for varicella, up from 43.2% the previous year. Coverage rates for poliovirus and measles, mumps, rubella (MMR) vaccine have remained stable, at slightly over 91%.
These national percentages vary considerably from one state to another, however, and for selected urban areas. For example, coverage for the 4:3:1 series (four doses of DTaP, three doses of poliovirus vaccine, and one dose of a measles-containing vaccine) was 66.9% in Detroit, compared with 77.2% for the rest of Michigan; in New Jersey, only 68.7% of the children in Newark are fully covered, compared with 81.5% in the rest of the state. The state with the highest rate of 4:3:1 coverage is Vermont, with 90.7%. Walter Orenstein, MD, director of the National Immunization program, calls the continued existence of low immunization rates in some parts of the country a "national tragedy" and urges all parents to talk to their health-care provider about immunization or to call the National Immunization Program hotline at 800-232-2522 (English) or 800-232-0233 (Spanish) for information.
The July 4th recess has come and gone, Congress is back in town, and legislation affecting children's health remains status quo. Nothing definitive is happening on the patients' bill of rights, Medicare funding, or stricter gun control regulations, other than the generation of issues on which each party hopes to hang the partisans of the other. President Clinton, on the campaign trail, praised the House version of patients' rights legislation and insisted that the Senate's bill was so lacking it was worse than no legislation at all. The bills differ in terms of coverage (161 million subscribers in the House version, 56 million in the Senate bill) and in the provisions concerning suits against HMOs (easier in the House version). The House version is backed by the American Medical Association.It is unlikely that the differences between the two bills will be reconciled before election day. The price of prescription drugs is another politically hot issue that will generate much campaign rhetoric in the coming months, but is unlikely to be resolved this year. Congressional gridlock does not preclude action in other branches of government, however. For example:
The Supreme Court issued a decision rejecting a patient's suit against an HMO. Writing for the court in this unanimous decision, Justice Souter held that ERISA (the Employee Retirement Income Security Act) precluded such suits in federal courts, and pointed out that this was a situation that only Congress had the power to change.
The National Center for Health Statistics has issued new children's growth charts, making use of the more accurate measure of body mass index for children age 2 and up and reflecting more recent data on average height and weight of children from birth to age 3. The new charts are the first revision in 23 years.
The Food and Drug Administration is holding public hearings on the way it regulates the sale of over-the-counter drugs, the first review of these policies the agency has conducted since OTC regulations were last changed in 1972. Agency spokesmen indicated that allowing OTC sale of such drugs as anticholesterols, birth control pills, and even antibiotics might be under consideration. Fearing that OTC status will encourage the overuse of antibiotics and therefore promote drug resistance, the IDSA, the Infectious Diseases Society of America, is vigorously opposing the move. If you agree with IDSA, now is the time to register your objections with the FDA.
The Agriculture Department, reacting to increasing numbers of outbreaks of foodborne disease, has put tougher standards into place for ground beef the federal government buys for the school lunch program. The new regs will not apply to ground beef that local school districts purchase, however.
The Consumer Products Safety Commission found that 21 of 25 children's crayons tested have significant amounts of "transitional fibers" similar to asbestos, and asked manufacturers to reformulate their productswhile admitting that the actual risk to children is quite low. Dixon Ticonderoga (makers of Prang crayons), Rose Art Industries, and Binney & Smith (Crayola) have said they will comply.
The National Academy of Sciences released a report from a panel of experts concluding that methylmercury in the environment presents an unacceptable health risk to children born to women who eat fish during pregnancy. The report cleared the way for tougher federal regulations governing mercury emissions.
The Environmental Protection Agency, doing an end run around Congressional moves to kill the proposal, issued new water pollution rules. Congress could undo this administrative action, but EPA Administrator Carol Browner thought it unlikely that opponents would want to go through the full-dress public review that would be necessary.
September 29, Perspectives in Medicine Expedition, Alaska. To register, call Charlotte de Frances, 800-633-4764
September 2528, National Association of Children's Hospitals, Philadelphia, PA. To register, call Jane Knops at 703-684-1355 or fax 703-684-1549
October 56, Children with Special Health Needs, New Orleans. Sponsored by the University of Massachusetts Medical School. To register, call Ted Purcell at 508-856-1908 or fax 508-856-6838
November 1819, Infectious Diseases in Children, New York City. To register, call JoAnne Kleiderlein at 609-848-1000 or fax 609-853-5991
November 2324, European Conference on Pediatric Asthma, London, UK. To register, call Donald Reinders at 44-1892-539606.
Julia McMillan. Updates.