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14 May 2013 Annals of Internal Medicine Tip Sheet

Below is information about an article being published in the May 7 issue of Annals of Internal Medicine. The information is not intended to substitute for the full article as a source of information. Annals of Internal Medicine attribution is required for all coverage.

1. U.S. Should Maintain a ‘High Level of Alert and Preparedness’ for Chinese Avian Flu

The United States should maintain a high level of alert and preparedness for influenza A (H7N9), as its global pandemic potential is still unknown. In March, Chinese public health officials notified the World Health Organization that an avian influenza virus that had never before been detected in humans had infected three adults, resulting in critical illness. Since then, more than 100 people have been infected, and 24 have died. About a fifth of those who have been infected are still critically ill, making experts worry about the implications of a potential pandemic. A disease must meet three criteria to be considered a pandemic. First, a substantial portion of the population should not have immunity. Since H7N9 has not yet been seen in humans, immunity is unlikely. Second, it has to be capable of causing disease. Several features of the virus suggest that H7N9 has adapted to infecting humans and is capable of causing severe disease. Third, and most critical, is the ability to efficiently transfer from human to human. Experts do not yet know if H7N9 has the ability to mutate and spread efficiently among humans. Currently, the disease remains hard to catch but dangerous for those who become infected. However, the detection of more than 100 cases in two months compared to roughly 600 human cases of H5N1 in a decade suggests that H7N9 is already more transmissible than H5N1, at least from poultry to humans. For now, H7N9 is a sporadic zoonosis restricted to East Asia. If the virus were to become a global pandemic, the United States would need to address some of its vulnerabilities with regard to vaccine production and its public health and clinical infrastructure. The deterioration of the public health workforce and limited surge capacity of a stressed healthcare system would prove dangerous in a pandemic.

2. U.S. Task Force Recommends Screening All Adults for Alcohol Misuse

The United States Preventive Services Task Force (USPSTF) recommends that clinicians screen all adults 18 and over, including pregnant women, for alcohol misuse. Clinicians should provide brief behavioral counseling interventions to patients engaged in risky or hazardous drinking. Alcohol misuse is the third leading cause of preventable death in the United States after tobacco use and being overweight, resulting in more than 85,000 deaths a year. “Alcohol misuse” is the term used to define a spectrum of behaviors. Harmful alcohol use is a pattern of drinking that causes physical or mental damage. Alcohol abuse is drinking that leads to failure to meet responsibilities, use of alcohol in physically hazardous situations, and/or having alcohol-related legal or social problems. Alcohol dependence (alcoholism) includes physical cravings and withdrawal symptoms, frequent consumption of alcohol in larger amounts over longer periods than intended, and a need for markedly increased amounts of alcohol to achieve intoxication. About 25 percent of the U.S. population admits to alcohol misuse, with most engaging in what is considered risky or hazardous drinking, or drinking more than is recommended during a given time period. Adequate evidence suggests behavioral counseling interventions reduce weekly alcohol consumption and promote long-term compliance with recommended drinking limits among patients engaging in risky or hazardous drinking. These interventions have also been shown to reduce binge drinking, which is characterized as heavy per-occasion alcohol use. The most effective interventions were brief (10 to 15 minutes per contact) multicontact interventions delivered by primary care physicians with some additional support from a nurse or health educator. Limited evidence suggests that brief behavioral counseling interventions are generally ineffective as singular treatments for alcohol abuse or dependence. The Task Force did not formally evaluate other interventions (pharmacotherapy or outpatient treatment programs) for alcohol abuse or dependence, but the benefits of specialty treatment are well established and recommended for persons meeting the diagnostic criteria for alcohol dependence. These recommendations differ from the 2004 statement in that the USPSTF has clarified the definition of alcohol misuse to include the full spectrum of drinking habits from risky to dependent. The Task Force emphasizes that evidence on the effectiveness of brief behavioral counseling interventions in the primary care setting remains largely restricted to persons engaging in risky or hazardous drinking. Evidence is lacking to recommend an optimal screening interval. The Task Force also found insufficient evidence to make recommendations for screening or behavioral interventions for adolescents.