C-Sections Recommended for HIV+ Pregnant Women

lthough cesarean births are rarely recommended before 39 weeks’ gestation, the American College of Obstetricians and A Gynecologists (ACOG), acting on new research, recommended in

late July that all HIV-positive pregnant women should be offered scheduled cesarean deliveries a t 38 weeks’ gestation. The recommendation aims to

reduce the risk of passing the AIDS-causing virus to newborns, ACOG indi- cated. The new recommendation results from published data that now show a scheduled cesarean, with zidovudine (ZDV) treatment, significantly reduces the risk of transmitting HIV to the infant to about 2 percent.

Women with HIV who aren’t taking ZDV and give birth vaginally have a 25 percent risk of passing the virus to their newborns. When both moth- er and baby, however, receive ZDV, the risk diminishes to between 5 and 8 percent. This risk is lowered even further-to about 2 percent-if both mother and newborn receive ZDV and the baby is delivered by a sched- uled cesarean delivery.

newborns has been steadily declining in the US., in large part because of increased testing of pregnant women and the increased use of prophylactic ZDV therapy for mothers and newborns. According to the Centers for Disease Control and Prevention, approximately 7,000 HIV-infected women give birth each year in the U.S.

remains unknown, but research suggests that much of it occurs during labor and delivery. Performing a cesarean delivery a t 38 weeks reduces the likeli- hood of onset labor or rupture of membranes. There’s no benefit of having a cesarean delivery if either of these occur spontaneously.

Also, ACOG points out that a woman’s choice of whether to deliver by cesarean must be respected. Because there’s an increased risk of morbidity with cesarean delivery among HIV-positive women, these women should be clearly informed about the risks. Furthermore, the latest combination drug regimens may reduce the risk of transmission to such a low level that cesarean delivery doesn’t offer any additional benefit. Health care practi- tioners should discuss the option of a scheduled cesarean delivery as early as possible with every pregnant HIV-positive woman, whether she’s taking antiviral therapy.

ACOG’s recommendation comes at a time when the HIV infection rate in

The precise method of HIV transmission from mother to newborn

Older Women Struggling With Pain Management early two-thirds of older, dis- N abled women report signifi-

cant pain in their backs, knees, hips, and feet and have considerable difficulty controlling it, according to new findings from the National Institute on Aging’s (NIA) Women’s Health & Aging Study.

The analysis, one of the first to look at doses of medication in rela- tion to pain, found that almost half

of women with severe pain took very small amounts of medication or no medication at all. And in a smaller percentage of cases, they took too much. This mismatch of pain to effective medication, the researchers said, suggests a need for more effective strategies of manag- ing pain in older people.

This portrait of pain among older women appears in the June

1999 issue of the American Journal of Public Health. The report is based on data from the Women’s Health & Aging Study, a collabora- tive project of NIA and researchers a t Johns Hopkins University.

1,002 participants age 65 and older in the Women’s Health & Aging Study, a longitudinal study designed to examine the causes and course of disability among older women. At the start of the study, participants had trouble in a t least 2 out of 4 functional “domains,” including mobility and basic self care tasks. For this analysis, researchers looked a t the severity of pain reported by the women, who had been asked to rate the pain in their lower backs, hips, knees, o r feet on a scale of 0 to 10 while walking, using stairs, o r standing upright. The type and dose of analgesic medications taken by the participants, such as aspirin, acetaminophen, or nonsteroidal anti-inflammatory drugs, were also recorded.

Approximately two-thirds of the women reported notable pain in the following percentages:

49 percent - severe pain 22 percent - moderate pain 10 percent - mild discomfort 20 percent - no pain

Researchers examined data on

October/No vem ber 1999 A W H O N N L i f e l i n e s 17

O N T H E i?d!g@

Late Embryo Implantations Fail Researchers at the National Institute of Environmental Health Sciences recently announced that fertilized human eggs that are implanted late are less likely to survive. Their work builds on accumulat- ing science that shows about one-third of all embryos fail, when clinical miscarriages are factored in. It's been known for more than a decade that about 25 percent of fertilized eggs fail to survive 6 weeks-so early that most women didn't even know they had been pregnant.

Now researchers say that the lost fetuses tend to be those that implant late, according to their research published in June 10th New England Journal of Medicine. The implantation of the fertilized egg in the wall of the uterus is necessary for the nourishment and growth of the fetus; the later that implantation occurs, the greater the risk for failure. Research demonstrates the following risks of loss per each consecutive late day of implantation:

9th day-1 3 percent chance of loss 10th day-26 percent chance of loss

~ 11 th day-52 percent chance of loss 12th day onward-82 percent chance of loss

There was, however, no association in the NIEHS study between late implantation and the clinical miscarriages that occurred later in pregnancy. The current report is based on the testing of daily urine samples from about 200 North Carolina women. This relatively large study in normal, fertile women confirms more tentative data from two small reports in 1991 and 1993.

~

For women with severe pain, the most frequent sites were the knees or hips, followed by lower back pain (about 21 percent) and foot pain (about 17 percent.) Additionally, researchers found that 79 percent of the study partic- ipants used some type of analgesic medication. Acetaminophen was used most frequently (41 percent), followed by aspirin (34 percent), and ibuprofen (1 1 percent). Combinations of two or more analgesics were used by 29 percent of the participants.

Although 8 7 percent of women with severe pain took at least some medication, researchers were surprised by the large proportion of women with severe pain who used very little medication. Approximately 41 percent took less than 20 percent of the maxi- mum recommended analgesic dose or used no pain reliever a t all. In contrast, 9 percent of the group used more medication than is rec- ommended, a finding that con- firms earlier reports.

SPOTLIGHT: 15 Top Cancer-Fighting Foods For the best protection against cancer, head to the produce aisles-not the pharmacy. This directive comes from a landmark report released in 1997 by the World Cancer Research Fund and recently commented upon in Women's Health Advisor, published by the Center for Women's Healthcare at Cornell Unversity. Researchers claim that the greatest cancer-fighting powers can be found in the following 15 foods:

1. Spinach 6. Tomatoes 11. Oats 2. Oranges 7. Sweet potatoes 12. Tea 3. Broccoli 8. Berries 13. Flaxseed 4. Onions and garlic 9. Black-eyed peas 14. Wheat germ 5. Papayas 10. Soy foods 15. Nonfat milk

To build a cancer-prevention diet, the experts at Cornell make the fol- lowing suggestions: H Choose at least three different colors of fruits and vegetables daily

and have 5 to 10 servings Choose three different textures of fruits and vegetables daily, including leafy, pitted, and melon

H Eat at least seven whole grain foods H Eat at least five different grains a week H Include one daily serving of legumes, such as lentils or split peas

Nore. Adapted from "Harnessing the Cancer-Fighting Power of Foods," 1999, Women's Heakh Advisor, 3, pp. 6-7.

CDC Says Postpone Rotavirus Vaccine for Infants

he CDC is recommending that T health care providers postpone using the rotavirus vaccine in infants-at least until November 1999-based on early surveillance reports of intussusception (a type of bowel obstruction that occurs when the bowel folds in on itself) among some infants who received rotavirus vaccine. Although intussusceptions occur among infants who have not received rotavirus vaccine, the CDC is currently collecting additional data that may indicate more clearly whether the rotavirus vaccine increases the risk of intussusception.

An estimated 1.5 million doses of rotavirus vaccine have been administered to infants since it was licensed on August 31, 1998. As of July 7, 1999, the Vaccine Adverse Event Reporting System (VAERS) has received 15 reports of intussus- ception. The rate of intussusception among children receiving the rotavirus vaccine appears to be

18 A W H O N N L i f e l i n e s Volume 3, Issue 5

increased in the first 2 to 3 weeks after vaccination. Health care providers should be aware of the possible increased risk and consider this diagnosis among children pre- senting these symptoms. Incidences of intussusception and other adverse events following vaccina- tion should be reported to VAERS. Reporting forms and information can be requested at (800) 822-7967 or at www.cdc.gov/nip/vaers.htm.

Rotavirus is the most common cause of severe diarrhea in children in the U.S. Virtually all children have one or more rotavirus infec- tion(s) in the first 5 years of life. Each year, rotavirus is responsible for approximately 500,000 health care provider visits and 50,000 hospitalizations. Severe diarrhea and dehydration occur primarily among children 3 months to 35 months of age, with the vast major- ity of cases occurring in the winter and spring months.

HIV Rapid Home Use Test Kit Gives Bad Results

n a joint investigation conducted I by the FDA and the Federal Trade Commission, an unapproved HIV rapid home use test kit, pro- moted on the Internet and sold domestically, was tested by the FDA and, in some cases, gave false nega- tive results. FDA is notifying con- sumers who purchased the “EZ MedTest,” marketed by Cyberlinx Marketing, Inc. on the Internet, that the test results given by the test are unreliable. Kit purchasers are advised to consult with a health professional regarding other avail- able FDA approved tests that detect antibodies to HIV.

The “EZ MedTest” website has been removed from the Internet by Cyberlinx Marketing, Inc. and the firm has voluntarily turned over all remaining test kits to FDA’s Office of Criminal Investigations. There is an ongoing FDA investigation of the U.S. firm that supplied the test kits to Cyberlinx Marketing, Inc. To read the FDA letter, surf to www. fda.gov/medwatch/sa fe- ty/1999/ezmedthtm.

Women Lead a Growing Group of Centenarians During the past 10 years, the number of centenarians has doubled- from about 37,000 to 70,000 currently. Analysts at the U.S. Census Bureau suggest that this per decade doubling trend may continue, with the centenarian population possibly reaching 834,000 by the middle of the next century.

National Institutes of Health, points out significant problems with information on the true ages of people 95 and older; however, the data are becoming more accurate with improvements in birth records. This tremendous growth in an aging, elderly population has tremendous implications for health care providers, particularly those who care for women. According to the report, the centenarians share many of the characteristics that census and other researchers have noted for people age 85 and above. Most significant are the fol- lowing characteristics:

Four out of every five centenarians are women. Despite the dra-

The report, funded by the National Institute on Aging (NIA) at the

matic slowing of death rates at the oldest ages over the past few decades, gains for men have been smaller and men still lag behind women in attaining age 100. Projections suggest that these differ- ences will continue into the middle of the 21st century. The centenarian population, mostly nonHispanic white currently, will become significantly more diverse in the coming years. Approximately 78 percent of today‘s centenarians are white, a pro- portion expected to decrease to about 55 percent by 2,050. The percentage of the older Black population is expected to remain at about 13 percent, and the proportion of Hispanics is expected to increase from 5.6 percent to about 20 percent. The proportion of older Asian and Pacific Islanders is expected to increase from about 3 percent to nearly 11 percent. Only about half of the centenarians counted in 1990 had completed some high school or more. This compares with four out of five peo- ple aged 65 through 69 in 1990 with at least some high school. The impact of educational attainment, a major determinant of health sta- tus, will be closely observed as the younger group, or cohort, moves toward very advanced age.

with about 10 percent of the total number living in California and 8 percent in New York. A state-by-state analysis shows that, propor- tionally, Iowa has the highest percentage of centenarians among its own population, followed by South Dakota.

Additional data from the report, ”Centenarians in the United States,”

The nation’s centenarians are concentrated on both US. coasts,

P23 1 99, is ava i I a b I e at w. census. gov/prod/99pubs/p60 7 99/pdf.

iologic Field Correction for imune Globulin Intravenous

ecent stability studies have shown ? that the anticomplementary activ- (ACA) of Venoglobulin S, 10 per-

n t may not remain stable for its >eled dating period of 24 months ien stored at 25” Celsius. Alpha Therapeutic Corp. has termined that, as a precautionary :asure, lots of Venoglobulin S, 10 rcent labeled with a storage tem- rature of “at or below 25” ,lsius” should be relabeled with

an expiration date of 12 months after manufacture; this is a change from the current 24-month dating period. Alpha Therapeutic Corp. will provide vial and carton labels to be affixed over the current label on any product remaining in inven- tory from the above-mentioned lots. There has been no increase in the incidence of adverse events reported with this product, and use of this product may continue. The lot numbers may be found at: http://www. fda.gov/cber/fprecalls/igi valpO70299. htm.

October/November 1999 A W H O N N L i f e l i n e s 19

Sunscreen on Infants as last Resort

new policy statement, from the A American Academy of Pediatrics (AAP) on the dangers of sun exposure, says that it may be safe to use sunscreen on infants younger than 6 months of age when adequate clothing and shade are not available. Previously, the use of sun- screen on infants younger than 6 months was not advised by the AAP. However, there is no evidence that using sunscreen on small areas of a baby's skin causes harm. In addition to possible sunburn, infants and children may be at increased risk for eye injury from the sun. The AAP says children, including infants, should wear hats with a brim and sunglasses designed to block at least 99 percent of the sun's rays. +

--Compiled and edited by Carolyn Davis -key

Comer Research challenges, aCIL'CUIces, and opportunities

Cancer Stcctistics

News in Brief HVC Update: Breastfeeding Doesn't Increase HCV Transmission Risk; Large Study to Commence in 2000 According to a new opinion from ACOG, breastfeeding doesn't appre- ciably increase the risk of transmitting hepatitis C (HCV) from mother to newborn. The opinion reflects recent guidelines from the CDC and supporting research that demonstrates that infection rate is about 4 percent in both breastfed and bottle-fed infants of women with HCV. According to ACOG, the average infection rate for infants born to women who are HCV-positive is now about 5 to 6 percent, depending on the viral load of HCV in the mother at the time of birth.

In other news, the NIDDK is funding the largest and longest study of hepatitis C undertaken in the U.S. In the 8-year clinical trial of antiviral drugs on treatment for chronic hepatitis C (HCV), researchers want to know if long-term treatment with these drugs can slow or prevent the progression of liver disease in HCV patients. Some, but not all, HCV patients develop cirrhosis or liver cancer, which can lead to death. The study will also provide information about the origins of hepatitis C and help researchers identify factors that predict or correlate with liver damage caused by HCV.

Nearly 4 million Americans are infected with hepatitis C, and the disease ranks with alcohol abuse as the most common cause of chronic liver disease. Hepatitis C leads to about 1,000 liver trans- plants in the U.S. every year. For more information, surf to www. niddk. nih.gov.

A New Resource Kit from the National Cancer Institute

% order this and other

materials, call the

Cancer Information Service,

a program of the

National Cancer Institute at

1 -800-4-CANCER (1 -800-422-6237)

People with TTYequipment, dial 1 - 800- 332- 8615

20 A W H O N N L i f e l i n e s Volume 3, Issue 5