Exercise and Fitness
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Every winter, about 1,200 Americans die from a heart attack or some
other cardiac event during or after a big snowstorm, and shoveling is
often the precipitating event.
Why is shoveling so hazardous?
- Shoveling uses your shoulders and arms, and upper body exercise
tends to put strain on the heart because those muscles aren’t
- Working in an upright position adds to the arduousness because blood
pools in the legs and feet, so to maintain blood pressure, your heart
must work harder.
- Much of snow shoveling is isometric exercise: your muscles are working,
but there's little actual movement until you finally heave a shovelful
up on the bank. During isometric exercise of any type, your heart rate
goes up, and your blood vessels constrict, presumably to send more
blood to the straining muscles. As a result, your blood pressure goes
- Without knowing it, shovelers sometimes perform a version of the Valsalva maneuver,
bearing down as they would during a bowel movement while holding their
breath. Waiting to exhale while straining like that can lead to abrupt
changes in your heartbeat and blood pressure.
- First thing in the morning, the time when many people dig out from
a storm, stress hormone levels tend to be higher, platelets in the
“stickier,” and heart attacks more likely.
- Shoveling involves exposure to the cold, another cardiac stressor.
- People who are out of shape often shovel, making the sudden intense
exercise even harder on the heart.
- Most people don’t warm up before they shovel or cool down afterward.
If you have a heart condition, you shouldn’t shovel under any
circumstances. People older than 50 should also try to avoid it. Contact
your local council on aging to see if they provide a list of teens in
your neighborhood who you can hire to do the job for you. Or buy a snow
blower. If you must shovel, take it easy. Rest often. Dress warmly and
stay well hydrated. Wherever possible, push the snow rather than lift
it. Clear only the snow that blocks your path into the house, the rest
will melt on its own. And of course, listen to your body. Head home if
you experience potential signs of heart trouble, including chest pain,
palpitations, undue shortness of breath, fatigue, lightheadedness, or
nausea. Also stop if your fingers or toes get numb or hurt — you
could have frostbite.
January 2003 Update
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Physical activity benefits
The frail health often associated with aging is in large part due to
physical inactivity, according to a report released by the U.S. Department
of Health and Human Services (HHS). It also advises that it’s never
too late to benefit from becoming physically active.
The report cites that even moderate levels of activity — such
as washing a car or raking leaves — can produce considerable benefits
that can be even more noticeable in older adults. Regular exercise improves
cholesterol levels, reduces blood pressure, cuts body fat, and lowers
blood sugar. Physical activity also improves bone and muscle strength.
All in all, people who exercise live longer — and they also live
Current guidelines recommend at least 30 minutes of moderate physical
activity a day. However, few older Americans reach this level. Lack of
physical activity and poor diets are the major causes of obesity, an
epidemic that is affecting people of all ages.
In the '70s and '80s, doctors were telling Americans to run; now, they
are asking people to walk. Walking can be a moderately intense aerobic
activity. But even at a more relaxed pace, walking has huge benefits.
The distance actually seems more important than the pace — and
it doesn't take heroic distances to get real benefit. In 1993, the Harvard
Alumni study found that men who walked just 1.3 miles a day had a 22%
lower death rate than those who walked less than 0.3 mile a day.
Strong muscles also improve your health. So set aside 15 minutes two
or three times a week for resistance or strength training as well as
10–15 minutes at least three times a week for stretching exercises.
The HHS report provides strategies that individuals, doctors, and even
communities can follow to promote physical activity. Individuals are
encouraged to take part in activities that they enjoy and to make them
a daily part of life. Doctors should help patients start and continue
these regimens and overcome any difficulties they encounter. Communities
can establish programs tailored to seniors’ physical activity needs
and improve walking or bike trails.
The complete report is available at www.ahrq.gov/ppip/activity.htm
August 2002 Update
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New guidelines for stroke prevention
With more than 700,000 Americans having strokes each year, doctors and
patients need to focus on stroke prevention. In light of this, the American
Heart Association (AHA) has issued a statement that details how to identify
and modify risk factors. Here are the AHA's tips, along with other general
guidelines for lowering stroke risk:
Blood pressure. You should get your blood pressure checked
at least every two years because many people with high blood pressure
don't even know they have it (130139 mm Hg systolic pressure over
8589 diastolic pressure is considered high-normal, while anything
above 140 over 90 is considered high). If you have high blood pressure,
the following lifestyle changes can help lower it:
- Eat more fruits and vegetables. Potassium-rich foods like bananas
and oranges may be especially good.
- Pass on salt. Salt makes the body hold onto water, and the heart
has to work harder to pump the extra fluid.
- Lose weight. The heavier you are, the harder your heart has to work
to pump blood to all parts of your body.
- Exercise. Even if you don't need to lose weight, exercise can reduce
high blood pressure and may even prevent it.
- Limit your alcohol. Having more than two alcoholic drinks a day significantly
increases your risk of high blood pressure.
- Quit smoking. Smoking increases your risk of heart attack, as well
as many other diseases. And if you live with a smoker, make sure he
or she quenches his cravings outside. Exposure to secondhand smoke
can double your risk of stroke.
- Learn to relax. Various kinds of behavioral therapy, like biofeedback,
yoga, and tai chi may lower blood pressure.
These lifestyle changes can also help with other causes of stroke, like
atherosclerosis (hardening of the arteries) and high cholesterol. If
the changes don't lower your blood pressure, your doctor may prescribe
a medication such as a diuretic or beta blocker.
Other conditions. The AHA recommends that patients with
diabetes and children with sickle cell disease closely monitor their
blood pressure with screenings every six months.
Non-modifiable risk factors. Black, Hispanic, Chinese,
and Japanese people are at increased risk for stroke compared to whites.
Men and postmenopausal women are also at higher risks than others. If
one of your parents had a stroke, you are at greater risk as well, either
because of genetics or shared lifestyle traits.
While you can't do anything about non-modifiable risk factors it's helpful
to know if you fall into a high-risk group so you can carefully monitor
July 2002 Update
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Asthma Education Leads to Improvement
Managing your child's asthma should include meeting with an asthma educator
a few times, according to a follow-up study. Presented at the meeting
of the American Academy of Allergy, Asthma, and Immunology, the study
reports that after attending an interactive training program three times
patients felt less worried about their asthma and had fewer asthma-induced
awakenings during the night. Both patients and their caregivers, who
also took part in the program, made better decisions about asthma care.
The 30 subjects, asthmatic children ages 6–12, underwent ACE IT!
(Asthma Care Education: Intensive Training), an interactive, small-group
education program. The sessions included a motivational talk by a teenage
athlete with asthma and a pharmacist's discussion of medications. A nurse
and asthma specialist also taught the participants about the clinical
nature of asthma, environmental controls, relaxation techniques, and
asthma action plans.
Researchers evaluated the children at the beginning and end of the training,
after six months, and again a year later. After the courses, the number
of patients reporting two or more nocturnal awakenings per month dropped
from 9 to 5, and the number of symptom-free days also improved, from
an average of 20 days per month to over 25 days per month.
The patients were more willing to use the tools available to them, such
as medications and peak flow meters, devises that asthmatics breath into
to help detect airway changes. They also worked harder to avoid things
that triggered their asthma, such as pets or dust.
The researchers plan to continue tracking these 30 children to study
the long-term effects on quality of life, morbidity, and cost of treatment.
A previous study published in the Journal of Allergy and Clinical
Immunology in 2000, found that the training program was much more
effective than simply handing out educational materials.
May 2002 Update
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New Cancer Prevention Guidelines
While some risk factors for developing cancer, such as family history,
can not be changed, there are ways for people to reduce their chances.
The American Cancer Society (ACS) recently released new dietary and physical
activity guidelines for cancer prevention.
One of the most basic tenets of a healthy diet is eating plenty of fruits
and vegetables. The ACS recommends eating no less than 5 servings of
a variety of fruits and vegetables every day. Many people have heard
of antioxidants but aren't sure exactly what they are or what they do.
Antioxidant nutrients (such as vitamin C, vitamin E, and carotenoids)
protect the body against the tissue damage that occurs as a result of
normal metabolism. Because such damage is associated with increased cancer
risk, the antioxidant nutrients are thought to protect against cancer.
Studies suggest that people who eat more vegetables and fruits, which
are rich sources of these antioxidants, have a lower risk for some types
of cancer, but studies of antioxidant supplements have not yet shown
a reduction in cancer risk.
Choosing whole grains over processed (refined) grains and sugars will
also help, so stick to whole grain rice, bread, pasta, and cereals. Also,
limit your red meat intake. When you do eat it, choose the way you cook
it carefully. While adequate cooking is necessary to kill harmful microorganisms
in meat, some research suggests that frying, broiling, or grilling it
at very high temperatures creates chemicals that might increase cancer
risk. Braising, steaming, and poaching meats cuts down on the production
of these chemicals.
Drinking too much alcohol is an established cause of cancers of the
mouth, throat, liver, and breast. Therefore, the ACS recommends limiting
alcoholic consumption to 2 drinks per day for men and 1 drink per day
The ACS also reminds people to remember that "low fat" or "fat
free" snacks like cakes and cookies are often high in calories.
High sugar intake can lead to obesity and elevated insulin levels, conditions
that increase cancer risk.
Physical activity is also an important component in the prevention of
cancer. Adults should engage in moderate-to-vigorous activity (walking,
leisurely bicycling, running, swimming) for 30 minutes or more at least
5 days a week.
Simple additions to your daily routine such as taking the stairs instead
of the elevator, taking 10-minute exercise breaks at work, and walking
to visit co-workers instead of emailing them are simple ways to increase
your activity level.
An unhealthy diet and lack of exercise can lead to weight gain and obesity,
conditions that are associated with developing cancers of the breast,
colon, endometrium, esophagus, gallbladder, pancreas, and kidney.
In addition to the general guidelines set forth by the ACS, there are
also answers to frequently asked questions about the rumored or theoretical
relationships between cancer and such substances as aspartame, beta-carotene,
calcium, coffee, fish oils, fluorides, folic acid, saccharin, and tea.
The ACS suggests that public, private, and community organizations create
environments that support the adoption and maintenance of these healthful
eating and physical activity behaviors. People should have access to
healthful foods in schools, at work sites, and when on daily outings
in their town or city.
For a copy of the complete set of guidelines, call the American Cancer
Society at 1-800-ACS-2345.
April 2002 Update
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Bicycle Helmets Save Lives
Although bicycling is one of the most popular sports, injuries associated
with bicycling are the leading cause of emergency room visits for children
and adolescents. Unfortunately, many of these injuries include head trauma.
Previous studies have shown helmets can sharply reduce the serious head
injuries that can occur with cycling. But the majority of children (and
their parents) still don't use helmets regularly. Why? Reasons suggested
include discomfort, lack of style, peer pressure, and not recognizing
the importance of helmets on short rides.
The American Academy of Pediatrics recently published a statement emphasizing
the importance of correct bicycle helmet use. In these recommendations,
all bicyclists (children and parents alike) should wear proper helmets
every time they ride. A helmet made after March 1999 should be used.
These newer helmets meet US Consumer Product Safety Commissions standards.
Children should be properly fitted because helmets come in several sizes.
Keep in mind that:
- In its correct position, the helmet should sit low on the forehead
and be parallel to the ground.
- Velcro pads should be placed in, or removed from, the inside of
the helmet as needed to make the helmet fit snugly.
- The chinstrap should be adjusted so that no more than two fingers
can be placed between the strap and the chin.
- The helmet should not shift or come off when the child shakes
- All helmets should be replaced every five years.
February 2002 Update
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Salt Restriction More Potent
Physicians often give patients with hypertension a daunting list of
lifestyle changes to help lower their blood pressure: lose weight, exercise
more, eat less salt, drink less alcohol, eat more foods rich in calcium,
potassium, and magnesium. Of course, these changes do work people
who follow them can reduce their need for medications or even do without
blood pressure-lowering drugs. But which of these lifestyle changes gives
you the biggest bang for your buck?
University of Colorado researchers recently compared the impact of exercise
or moderate salt restriction in 35 healthy older women with high-normal
blood pressure or mild hypertension (systolic blood pressure 130159
mm Hg), none of whom were using drugs to lower their blood pressure.
Half the women exercised for three months starting at 30 minutes
a day three or four times a week and working up to 45 minutes a day every
day, if possible. The other half tried to reduce their daily salt intake
to less than 2.4 grams of sodium (the amount in a level teaspoon of table
salt) without otherwise changing their diets. All were asked to try to
avoid gaining or losing weight.
The clear winner, reported in the American Journal of Cardiology,
was sodium restriction. Among the women who ate less salt, average systolic
blood pressures fell 16 mm Hg, compared with a still-respectable 5 mm
Hg in the exercise group. By the study's end of the study, systolic blood
pressure was lower in 88% of the women who ate less salt and in 55% of
So if you're trying to lower your blood pressure, should you just forget
about exercise and work harder at eating less salt? No. Exercise has
other benefits besides lowering blood pressure it can help control
weight, improve the cholesterol profile, stave off diabetes, and keep
bones strong. The real message from this study is that everyone should
exercise, but that people who are trying to control blood pressure should
lower their sodium intake, too.
December 2001 Update
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Diet and Exercise Dramatically Delay
Type 2 Diabetes
Americans at high risk for type 2 diabetes can sharply lower their chances
of getting the disease with diet and exercise, according to the results
of a major clinical trial. The same study also found the oral diabetes
drug metformin (Glucophage) reduces diabetes risk, though less dramatically.
The findings came from the Diabetes Prevention Program (DPP), a major
clinical trial comparing diet and exercise to metformin in 3,234 people
with impaired glucose tolerance, a condition that often precedes diabetes.
Smaller studies in China and Finland had previously shown diet and exercise
can delay type 2 diabetes in at-risk people. But the DPP, conducted at
27 centers nationwide, is the first major trial to show diet and exercise
can effectively delay diabetes in a diverse American population of overweight
people with impaired glucose tolerance (IGT). IGT is a condition in which
blood glucose levels are higher than normal but not yet diabetic.
Of the 3,234 participants enrolled in the DPP, 45 percent are from groups
that suffer disproportionately from type 2 diabetes: African Americans,
Hispanic Americans, Asian Americans and Pacific Islanders, and American
Indians. The trial also recruited others known to be at higher risk for
type 2 diabetes, including people age 60 and older, women with a history
of gestational diabetes, and people with a first-degree relative with
type 2 diabetes.
Participants ranged from age 25 to 85, with an average age of 51. All
had impaired glucose tolerance as measured by an oral glucose tolerance
test, and all were overweight, with an average body mass index (BMI)
of 34. They were randomly assigned to one of the following groups: intensive
lifestyle changes with the aim of reducing weight by 7 percent through
a low-fat diet and exercising for 150 minutes a week; treatment with
the drug metformin (850 mg twice a day), approved in 1995 to treat type
2 diabetes; and a standard group taking placebo pills in place of metformin.The
latter two groups also received information on diet and exercise.
During an average follow up of about 3 years, about 29 percent of the
group receiving standard treatment developed diabetes. In contrast, 14
percent of the diet and exercise, and 22 percent of the metformin arms
developed diabetes. Volunteers in the diet and exercise arm achieved
the study goal, on average a 7 percent or 15-pound weight
loss, in the first year and generally sustained a 5 percent total loss
for the study's duration. Participants in the lifestyle intervention
arm received training in diet, exercise (most chose walking), and behavior
In all, participants in the random intensive lifestyle intervention reduced
their risk of type 2 diabetes by 58 percent, and those who received metformin
reduced their risk of getting type 2 diabetes by 31 percent.
September 2001 Update
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Walk, Don't Run for Weight Loss
People often disrupt their sedentary lifestyles with bouts of high-intensity
exercise, like running or aerobics, to avoid gaining weight or developing
heart disease. But a new study shows spending some of your day engaged
in moderate activity, like biking, walking, or even taking the stairs
at work, may be more a successful method for boosting daily calorie expenditure
and losing weight.
The study, published in Nature, involved 30 healthy, non-obese
women and men. For two weeks, the participants energy expenditure
was measured, while their activity levels were tracked using portable
motion sensors and activity diaries. The investigator found the amount
of moderate activity, not vigorous exercise, was a significant predictor
of total energy expenditure. He hypothesized that moderate activity usually
occupies a larger portion of the day compared to more vigorous exercise.
For instance, studies on obese subjects have found adding intense exercise
to diet didnt enhance weight loss because the extra energy expenditure
didnt offset the reduced time spent on other physical activities.
This small, but informative study provides strong evidence that exchanging
some of time you sit in front of a TV for moderate activity increases
total daily energy expenditure and metabolic rate. Short bursts of vigorous
activity in an otherwise inactive and unhealthy lifestyle is not enough.
So take the stairs, not the elevator, and go for a walk at lunch. But
dont be discouraged from going for a run. Aerobic activities, like
jogging, swimming and brisk walking, help make your heart stronger and
more efficient, which can lower your heart disease risk still further.
June 2001 Update
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National Cholesterol Education Program Releases
New Guidelines for Treating and Preventing High Cholesterol
On May 15, 2001, the National Cholesterol Education Program (NCEP)
coordinated by the National Heart, Lung, and Blood Institute (NHLBI)
released the first major revision of its recommendations for detecting
and lowering high cholesterol in adults since 1993.
One of the fundamental features of the new guidelines is the accurate
assessment of heart disease risk using a new "global risk assessment
tool" that combines multiple risk factors into a measure of a person's
absolute risk of developing coronary heart disease within the next 10
years. According to the guidelines, patients who have a risk of 20% or
higher should receive aggressive therapy to control cholesterol levels.
In addition to aggressive treatment of high LDL cholesterol, as laid
out in the 1993 report, the revised guidelines also recommend a more
assertive treatment approach for diabetes, low HDL levels, and high triglyceride
Specific changes include:
- Treating high cholesterol more aggressively for those with diabetes,
even if they do not have heart disease.
- A full lipid profile (which measures total cholesterol, LDL,
HDL, and triglycerides) as the first test for high cholesterol (rather
than simply testing total cholesterol and HDL and performing a full
lipid profile only if total cholesterol is high).
- A new level at which low HDL becomes a major risk factor for heart
disease. The 1993 guidelines defined a low HDL as less than 35 mg/dL;
now it is less than 40 mg/dL.
- More aggressive treatment of high triglyceride levels.
- Advising against the hormone replacement therapy (HRT) as an alternative
to cholesterol-lowering drugs for post-menopausal women.
Another key change in the guidelines is intensified lifestyle recommendations
regarding nutrition, exercise, and weight control to treat high cholesterol.
The updated diet advises that less than 7% of daily calories come from
saturated fat and limits dietary cholesterol to less than 200 mg per
day. It also allows up to 35% of daily calories from total fat, provided
most come from unsaturated or monounsaturated fat, which doesn't raise
cholesterol levels. Additionally, the guidelines strongly underscore
the need for weight control and physical activity, both of which improve
various heart disease risk factors.
The revised recommendations also emphasize careful attention to the metabolic
syndrome, a particular cluster of cardiovascular risk factors that
is becoming increasingly common in the United States. Characteristics
of metabolic syndrome include too much abdominal fat, high blood pressure,
high blood sugar, elevated triglycerides, and low HDL.
For more information, see the "Live Healthier, Live Longer"
Web site by going to the NHLBI home page at www.nhlbi.nih.gov and
clicking on ATP III Cholesterol Guidelines under Highlights.
| 2001 Cholesterol Guidelines
|Total Cholesterol Level
||Total Cholesterol Category
|Less than 200 mg/dL
|240 mg/dL and above
|LDL Cholesterol Level
||LDL Cholesterol Category
|Less than 100 mg/dL
||Near optimal/above optimal
|190 mg/dL and above
|| Very high
|Less than 150 mg/dL
|| Borderline high
|Greater than or equal to 500
|HDL Cholesterol Level
||HDL Cholesterol Category
|Less than 40 mg/dL
||Low (representing increased risk)
|60 mg/dL and above
||High (heart protective)
| Three Categories of Risk that Modify
LDL Cholesterol Goals
| Risk Category
|| LDL Goal (mg/dL)
|Coronary Heart Disease (CHD) and CHD equivalents
||Less than 100
|Multiple (2+) risk factors
||Less than 130
|0-1 risk factor
||Less than 160
|Risk factors (exclusive of LDL cholesterol):
cigarette smoking; blood pressure greater than or equal to 140/90
mm Hg or on antihypertensive medication; HDL cholesterol less
than 40 mg/dL; a family history of coronary heart disease before
age 55 in a father or brother or age 65 in a mother or sister;
age above 45 for men and 55 for women
May 2001 Update
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More Evidence That Pumping Iron Is
Good for Seniors Too
Two recent studies published in the Journal of the American Geriatrics
Society add more data to the mounting evidence that exercise is
important at any age and that resistance (or weight) training has considerable
benefits for older adults.
It is well known that strength training can improve muscle strength
and balance of particular importance in preventing falls and fractures
in seniors. Research on just how much training is required to derive
these benefits has been conducted primarily in younger people. The first
study looked at how often older people must exercise. Forty-six people
(both men and women) between the ages of 65 and 79 years were assigned
to a resistance exercise program to be performed one, two, or three days
per week. Study results showed that seniors exercising one or two times
per week had about the same improvements in muscle strength and coordination
as did those who exercised three times per week.
Researchers at the University of Maryland Exercise Science Laboratory
conducted the second study, which was designed to look at the effects
of strength training on resting blood pressure in older adults (the average
age in this study was roughly 69). Eleven men and 10 women who had not
been exercising regularly were assigned to a six-month training program
using weight lifting machines. Not only did the study volunteers show
significant increases in upper- and lower-body strength, but both groups
also demonstrated significantly lowered diastolic blood pressure (the
bottom number in a blood pressure reading). Interestingly, only the men
in the group experienced significantly lowered systolic blood pressures
(the top number in a blood pressure reading). Perhaps the best news was
that the reduction in blood pressure brought these patients readings
into the normal range. Investigators also noted that the improvement
in blood pressure was not related to weight loss associated with increased
The bottom line, however, is not news at all. Exercise is important,
good for individuals of every age group, and the health benefits are
many. Even doing a little is a whole lot better than doing no exercise
Journal of the American Geriatrics Society, Vol. 47, No.
10, pp. 120814.
Journal of the American Geriatrics Society, Vol. 47, No.
10 pp. 121521.
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Walking for Women: A Great Step Toward Fitness
Ask any doctor for his or her advice for healthy living and you'll find
exercise a part of the prescription. However, it is one that patients
must "fill" themselves and that can be tough. The most recent guidelines
from the Centers for Disease Control and Prevention, the American College
of Sports Medicine, and the Surgeon General's report recommend that individuals
get at least 30 minutes of moderate-intensity activity on most (ideally
all) days of the week. Yet 60% of Americans don't regularly engage in
physical exercise at all.
Harvard Medical School researchers recently compared the effects of brisk
walking with more vigorous forms of exercise, specifically in women.
For this report, study investigators followed 72,488 women participating
in the Nurses' Health Study for 11 years. At the start of the study in
1986, these women were all between the ages of 40 and 65 and had no known
heart disease or cancer. They completed regular, detailed questionnaires
about their physical activity.
Researchers found that vigorous exercise and brisk walking reduces the
risk of heart attack for women by roughly the same amount. The bottom
line is that brisk walking for three or more hours per week can reduce
a woman's risk of cardiovascular disease by 30%-40%. Women who walk for
a longer time or combine walking with other vigorous physical activity
can expect to reduce their risk of heart disease even more. So women
don't have to sign up for aerobics or train for a marathon to substantially
reduce their heart disease risk. A good start is putting one foot in
front of the other at a good pace. For more information on exercise and
fitness, see page 51 of the Family Health Guide.
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New Pneumococcal Vaccine for Children Less Than
Two Years Old
A new vaccine called Prevnar is the first vaccine to protect children
less than two years old against the bacteria Streptococcus pneumoniae,
which is the leading cause of pneumonia, bacterial meningitis, bacteremia,
sinusitis, and acute otitis media, or middle-ear infections, in young
children. In addition to protecting children from pneumococcal infection,
vaccination with Prevnar also decreases transmission of pneumococci from
one child to another, an effect known as "herd immunity." Furthermore,
since middle-ear infections are the leading reason that children need
to take antibiotics, vaccination with Prevnar could reduce the need for
antibiotics in this age group. This, in turn, should slow or reverse
the trend of antimicrobial resistance. A different pneumococcal vaccine,
known generically as PPV23, has been available to adults for years, but
it has not been effective in children less than two years old.
The Centers for Disease Control and Prevention's (CDC's) Advisory Committee
on Immunization Practices (ACIP) recommends that all children less than
two years old should be vaccinated with Prevnar. Children aged two to
five years old should receive a two-shot series of Prevnar followed by
one dose of PPV23 if they are high-risk, a category that includes children
with HIV, immunocompromising conditions, chronic illness, or sickle cell
disease. Prevnar may also be considered for children between two to five
years with priority given to those who are between the ages of 24 and
35 months, of African-American, American Indian, or Alaska Native descent,
or who attend group day care centers.
Since Prevnar has not been studied sufficiently in children older than
five years who are at high risk for serious pneumococcal disease, ACIP
continues to recommend that children five and older receive PPV23.
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