Download investigators to replicate them. As Drs. Chia and Chia hypothesize [1

investigators to replicate them. As Drs.
Chia and Chia hypothesize [1], localized
tissue infection, such as cytomegalovirus
(CMV) viremia, could be present in persons with CFS, but CMV viruria and localized CMV mucosal infection, as well as
localized mucosal Epstein-Barr virus infection, are often present in asymptomatic
persons. Drs. Chia and Chia may want to
associate an infectious agent found anywhere on a mucosal surface or specimen
with the underlying illness. Medical science shows that such thinking is neither
correct nor meets standards of scientific
rigor.
In addition, the published abstract concerned with enterovirus detection that was
cited by Chia and Chia [2] included 4
control subjects. RT-PCR is technically demanding, and extreme rigor is required to
exclude artifacts of amplification. Therefore, we await confirmation of the results
of their findings, including blinded assays
on specimens from matched control subjects. We certainly agree that further research is needed and that the infectious
agents listed by Chia and Chia [1] are reasonable to study. Rigorous studies that
help provide new insights into the etiology
of CFS and help develop treatments for
the many individuals with CFS are urgently needed.
David M. Koelle,2,5 Serge Barcy,4
Meei-li Huang,4 Rhoda L. Ashley,1
Lawrence Corey,1,2,4 Judy Zeh,3
Suzanne Ashton,2 and Dedra Buchwald2
Departments of 1Laboratory Medicine, 2Medicine,
and 3Statistics, University of Washington,
4
Fred Hutchinson Cancer Research Center,
and 5Harborview Medical Center,
Seattle, Washington
References
1. Chia JKS, Chia A. Diverse etiologies for chronic
fatigue syndrome [letter]. Clin Infect Dis
2003; 36:671–2 (in this issue).
2. Chia JK, Jou NS, Najera L, et al. The presence
of enteroviral RNA (EV RNA) in peripheral
blood mononuclear cells (PBMC) of patients
with the chronic fatigue syndrome (CFS) associated with high levels of neutralizing antibodies to enteroviruses [abstract 405]. Clin Infect Dis 2001; 33:1157.
Reprints or correspondence: Dr. David M. Koelle, Dept. of
Medicine, Harborview Medical Center Mail Stop 359690, 325
Ninth Ave., Seattle, WA 98104 ([email protected]).
Clinical Infectious Diseases 2003; 36:672–3
2003 by the Infectious Diseases Society of America. All
rights reserved. 1058-4838/2003/3605-0021$15.00
Removing Hospitalization
as a Barrier to Immunization
Sir—We read the editorial by Poland [1]
and agreed with many of his excellent
points in regard to influenza immunization practices. He provides an excellent
review of current practices, the strengths
and weaknesses of published findings regarding influenza vaccination, and the implications of these findings for patient
care. We would like to share some of our
thoughts concerning this commentary
and some of our experiences in trying to
improve vaccination rates in our hospital.
The author correctly identifies physicians and the health care system as barriers
to improving vaccination rates and saving
lives. Isn’t it ironic that patients can authorize their own vaccinations in grocery
stores, pharmacies, and shopping malls
but that patients in hospitals who are at
risk for influenza can not be vaccinated
until the doctor writes a medication order?
Grabenstein [2] published an excellent review of vaccination myths that are oftentimes perpetuated by well-meaning health
care organizations and professionals. In
our practice, we frequently encounter providers who contribute unwittingly to misbeliefs that discourage vaccination. Overcoming these myths requires diligent,
well-planned, and consistent educational
efforts. In addition to education, it is often
necessary to develop programs that minimize or eliminate the potential for these
misconceptions to prevent at-risk patients
from receiving needed vaccines.
We appreciate Poland’s thoughts regarding how we might achieve universal
influenza vaccination. As Poland [1]
stated, the use of standing orders, nursebased screening, and chart reminders for
physicians has been shown to be effective.
Recently, we published our experience
with incorporating pneumococcal immunization screening into critical pathways [3]. Although numerous tools or
mechanisms for improving immunization
rates exist [4], we believe that the establishment of a consistent, systematic process for immunization assessment and
vaccine administration is more important
than the methods employed. A system that
identifies all at-risk patients and clearly assigns responsibility for patient monitoring
and follow-up is critical for success. Handoffs of patients from one health care professional to another or from an inpatient
setting to an ambulatory care setting must
be avoided. Whoever identifies a patient
who needs vaccination should have the
authority, knowledge, and responsibility
to act. Otherwise, yet another vaccination
opportunity may be missed.
Finally, we would encourage everyone
concerned with improving immunization
rates to consider including pharmacists as
important partners in such efforts. Since
pharmacists are skilled at medication
counseling, they can be especially effective
as immunization educators. A recent position paper published by the American
College of Physicians–American Society of
Internal Medicine advocated “the use of
the pharmacist as immunization source,
host of immunization sites, and immunizer” [5, p. 82]. Given the dismal national
immunization figures and the lofty
Healthy People 2010 goals [6], pharmacists in hospitals, clinics, and the community are in a great position to be important contributors to this great cause.
We would also agree with Poland [1] that
Medicare and other insurers should reimburse physicians fairly for the costs of
vaccination. Furthermore, we believe that
many groups of health care professionals
(in particular, nurses, nurse practitioners,
and pharmacists) should be recognized
as providers of this important service and
should be appropriately compensated.
In conclusion, we salute Poland’s [1]
ideas regarding the prevention of avoidable influenza-associated morbidity and
CORRESPONDENCE • CID 2003:36 (1 March) • 673
mortality. The elimination of myths and
barriers to vaccination for patients and
health care professionals will go a long way
toward making this high-impact, seemingly simple goal a reality.
Mark Woods and Jill T. Robke
Pharmacy Department, Saint Luke’s Hospital,
Kansas City, Missouri
References
1. Poland GA. If you could halve the mortality
rate, would you do it? Clin Infect Dis 2002; 35:
378–80.
2. Grabenstein JD. Vaccine misconceptions and
inappropriate contraindications lead to preventable illness and death. Hosp Pharm 1998;
33:1557–67.
3. Robke JT, Woods M, Heitz S. Pharmacist
impact on pneumococcal vaccination rates
through incorporation of immunization assessment into critical pathways in an acute care
setting. Hosp Pharm 2002; 37:1050–4.
4. Fedson DS, Houck P, Bratzler D. Hospitalbased influenza and pneumococcal vaccination:
Sutton’s law applied to prevention. Infect Control Hosp Epidemiol 2000; 21:692–9.
5. Keely JL. Pharmacist scope of practice. Ann
Intern Med 2002; 136:79–85.
6. Healthy People 2010. Healthy people 2010: understanding and improving health. November
2000. Available at: http://www.healthypeople.
gov/publications/default.htm. Accessed 12 September 2002.
Reprints or correspondence: Dr. Mark Woods, Pharmacy Dept.,
St. Luke’s Hospital, 4401 Wornall Rd., Kansas City, MO 64111
([email protected]).
Clinical Infectious Diseases 2003; 36:673–4
2003 by the Infectious Diseases Society of America. All
rights reserved. 1058-4838/2003/3605-0022$15.00
signs responsibility for patient monitoring
and follow-up is critical for success” [1, p.
673]. These are highly significant statements and I could not agree more with
the assessment of Woods and Robke. The
issue is how to institutionalize such critical
pathways for vaccination as clearly defined
procedures in the variety of health care
settings in which vaccinations can or
should be provided. Although this means
that the health care system must engage
in the hard work of defining and codifying
such critical pathways, the reward is great.
In fact, no other medical maneuver is as
cost-effective as the prevention of disease
by immunization. We must clearly recognize the opportunity to save tens of
thousands of lives annually through the
simple administration of a vaccine.
Woods and Robke [1] also highlight the
inclusion of pharmacists as partners in immunization efforts. Again, I agree that
pharmacists can be effective immunization educators. Partnerships throughout
the health care professional continuum
can only increase the opportunities to intervene successfully and to provide, not
only education, but the vaccines themselves. My hope is that health care professionals would take the opportunity to
save lives with a maneuver as simple as
vaccination so seriously that they would
themselves become advocates for incorporating critical pathways and systems
into the settings in which they practice.
Reply
Gregory A. Poland
Sir—The letter by Woods and Robke [1]
in response to my article entitled “If You
Could Halve the Mortality Rate, Would
You Do It?” [2] offers several excellent and
important points that deserve highlighting. In particular, the authors stress their
experience with the use of critical pathways to increase screening for pneumococcal immunization. Woods and Robke
state that “the establishment of a consistent, systematic process for immunization
assessment and vaccine administration
is…important” and that “a system that
identifies all at-risk patients and clearly as-
Mayo Vaccine Research Group, Departments
of Medicine, Infectious Diseases, and Molecular
Pharmacology and Experimental Therapeutics,
Mayo Clinic, Rochester, Minnesota
Reference
1. Woods M, Robke JT. Removing hospitalization
as a barrier to immunization [letter]. Clin Infect
Dis 2003; 36:673–4 (in this issue).
2. Poland GA. If you could halve the mortality
rate, would you do it? Clin Infect Dis 2002; 35:
378–80.
674 • CID 2003:36 (1 March) • CORRESPONDENCE
Reprints or correspondence: Dr. Gregory A. Poland, Mayo
Vaccine Research Group, Depts. of Medicine, Infectious Diseases, and Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, 200 First St. SW, Rochester, MN 55905
([email protected]).
Clinical Infectious Diseases 2003; 36:674
2003 by the Infectious Diseases Society of America. All
rights reserved. 1058-4838/2003/3605-0023$15.00
Diagnosis of Rabies
by Use of Brain Tissue
Dried on Filter Paper
Sir—Rabies surveillance and reporting are
poor in developing countries, and most
governments fail to appreciate either the
public health or the economic burden imposed by human and animal rabies [1].
Although postmortem diagnosis of rabies
can easily be made by fluorescent antibody
testing (FAT) of a brain impression smear,
such analysis is of limited availability in
developing countries [1]. Moreover, transfer of the specimens to the laboratory for
performance of FAT must be done within
24 h after specimens were collected, before
the brain starts to decompose [2]. Alternatively, brain tissue can be stored frozen
at the collection site and during transport.
However, this is not always possible in remote areas where the availability of electricity remains problematic. A simple
method for analysis of HIV RNA level in
blood spotted on filter paper has been described previously [3]. We report that both
nucleic acid sequence-based amplification
(NASBA) and RT-PCR can detect rabies
virus RNA in brain tissue that has been
dried on filter paper and stored for 222
days.
Samples of 10 control dog brains and
10 rabies-infected dog brains were obtained from the rabies diagnostic unit at
Queen Saovabha Memorial Institute
(Bangkok, Thailand). The temperature of
the samples was kept at ⫺80C until analysis was performed. Ten milligrams of each
brain tissue sample was spotted on filter
paper (product no. 903; Schleicher &
Schuell). The samples were allowed to
thoroughly saturate the filter paper, which
was then air dried for 12 h. The filter paper
was overlaid by a wraparound cover,
which was then enclosed in a paper en-