U.S. Births Decline; Economy to Blame?

August 30, 2010 — The number of babies born in the United States declined an estimated 2.6% in 2009 compared to the previous year, the CDC says. And it may be the result of the downturn in the economy.
The new report, by the CDC’s National Center for Health Statistics, says provisional data indicate that an estimated 4,136,000 babies were born in 2009, compared to 4,247,000 in 2008.
The report also found that:

• Births also dropped in 2008, compared to the previous year, with an estimated 4,251,095 babies born.
• In the preliminary analysis for 2008, births dropped for women under 40, but increased for women 40 and over. The decline in births in 2009 may well be associated with the severe downturn in the U.S. economy, which started late in 2007. But it’s too early to know for sure until more statistics are available.

Preliminary Data
The statistics are contained in National Vital Statistics Reports, a publication of the CDC and its National Center for Health Statistics.
It presents early data from all 50 states and Washington, D.C., plus Puerto Rico, but stresses the statistics are preliminary.
The study also reports that:

• The busiest month for births in 2009 was July, when 369,000 babies were born. In 2008, July also witnessed the greatest number of births, 376,000.
• California had the most live births in both years, 530,659 in 2009, down from 551,592 in 2008.
• The fewest number of births in 2009 occurred in Vermont, where 6,118 live births were recorded. Vermont also had the fewest births in 2008 -- 6,275. California reported the most marriages for the second straight year, 213,922, down considerably from 247,022 in 2008. Washington, D.C., reported the fewest number of marriages in 2009 at 1,892, a significant drop from 2,367 in 2008.

SOURCES:
Tejada-Vera, B. National Vital Statistics Reports, Aug. 27, 2010; vol 58.

Exercise Can Treat Cardiovascular Disease as Well as Prevent It

August 30, 2010 (Stockholm, Sweden) — A series of presentations here at the European Society of 2010 Cardiology Congress emphasized how even moderate regular exercise can reverse the damage of existing heart disease while also preventing it.
In one such study, from a session entitled "Exercise: From leisure activity to a therapeutic option,"Dr Brage Amundsen (Norwegian University of Science and Technology [NUST], Trondheim) explained how his group is learning how to improve heart-failure patients' peak oxygen consumption (VO₂). Low peak VO₂ is a driver of poor prognosis in postinfarction heart-failure patients, he explained. The NUST group has conducted similar studies on the benefits of interval training for patients with metabolic syndrome.
Amundsen's group is preparing the randomized SMARTEX-HF study comparing aerobic interval training with moderate continuous training in about 200 patients. The interval-training regimen is built on four four-minute intervals walking on the treadmill at 90% to 95% of peak heart rate, with three-minute "active pauses"--walking at 50% to 70% of peak heart rate--between each interval. Including warm-up and cool-down periods, the total workout lasts 38 minutes. Patients in the moderate continued-training group will walk continuously at 70% to 75% of peak heart rate for 47 minutes.
Preliminary studies show that patients using the interval regimen improve their peak VO₂by a much larger margin than the moderate continuous-training group and that patients in the interval-training group exhibited reverse left ventricular remodeling, reduction in pro-B-type natriuretic-peptide (proBNP)--a marker of hypertrophy and severity of heart failure--and improvement in left ventricular ejection fraction. In vitro cell studies showed that interval training was associated with a reduction of endothelial-cell volume, and functional measures of single myocytes indicate improvements to muscle contractility and oxygen consumption in the interval group.
"A lot of people think this [high-intensity exercise] must be very hard, so we have to be a bit more realistic and inform the patients that it's not that hard and that anybody can do it," he said.
A Role for Strength Training
In a separate presentation, Dr François Carré (Hôpital Pontchaillou, Rennes, France) described research on a variety of exercise modalities showing that cardiovascular patients benefit from strengthening large muscles in addition to aerobic exercise, so "well-done" resistance training should be encouraged on top of aerobic exercise. His group's research has shown that the benefits of exercise generally far outweigh the risks for cardiovascular-disease patients, but exertion does increase the risk for cardiovascular adverse events, "so the physician must evaluate the individual risk, propose an individual program, and give a good education to the patients."
As well, Dr Rainer Rauramaa (Kuopio Research Institute of Exercise Medicine, Finland) presented research that suggests regular moderate-intensity exercise ought to be considered a "cornerstone" in the treatment of hypertension even if the impact is modest.
Early studies suggested that exercise did not improve resting blood pressure, but a more detailed look at the data showed that genetic factors play a major role in determining the response of a patient's blood pressure to exercise. Rauramaa's group also found that exercise's influence on blood pressure lasts only a few days, so the earlier studies may have simply missed the benefit of exercise by measuring the patients' blood pressure several days after their last exercise. His group found an improvement in carotid intima-media thickness in patients who exercised, but the improvement did not appear until three years into their study.
"There was a clear antiatherosclerotic effect of exercise." He pointed out that the antihypertensive benefits of exercise can be achieved even without weight reduction.

Dr Rainer Hambrecht

Finally, Dr Rainer Hambrecht (HerzzentrumBremen, Germany) presented unpublished results from the PET Multicenter study. As reported by heartwire , that study, showing that 12 months of exercise training was just as good as PCI for myocardial perfusion and symptom relief in patients with stable angina, had to be stopped early due to slow enrollment, but the data from the patients who were enrolled plus the results from a small pilot study show that both strategies improve myocardial perfusion, angina threshold, and exercise capacity. However, only exercise improves endothelial function and slows the progression of disease, because PCI is only a local palliative therapy, while exercise training has an impact on the underlying disease in the entire coronary tree, Hambrecht said.
"I would be happy if I could convince everybody with coronary artery disease to participate in a moderate exercise program," he said. He recommends patients stick to the professional guidelines by exercising three or four times a week, 30 minutes per session, at moderate exertion. He cited previous studies showing that patients who attempt to exceed that effort are at increased risk for potentially lethal arrhythmias.

Black Rice Is Cheap Way to Get Antioxidants

August 27, 2010 — Inexpensive black rice contains health-promoting anthocyanin antioxidants, similar to those found in blackberries and blueberries, new research from Louisiana State University indicates.
"Just a spoonful of black rice bran contains more health promoting anthocyanin antioxidants than are found in a spoonful or blueberries, but with less sugar and more fiber and vitamin E antioxidants," Zhimin Xu, PhD, of Louisiana State University Agricultural Center, says in a news release. "If berries are used to boost health, why not black rice and black rice bran?"
Xu and colleagues analyzed samples of black rice bran from rice grown in the Southern U.S.
He says black rice bran would be a unique and inexpensive way to increase people's intake of antioxidants, which promote health.
Black rice is rich in anthocyanin antioxidants, substances that show promise for fighting cancer, heart disease, and other health problems, Xu says.
He adds that food manufacturers could use black rice bran or bran extracts to boost the health value of breakfast cereals, beverages, cakes, cookies, and other foods.
Black Rice vs. Brown Rice
The most widely produced rice worldwide is brown. Millers of rice remove the chaff, or outer husks, from each grain to make it brown.
White rice is made when rice is milled more than is done for brown rice; the bran is also removed, Xu says.
The bran of brown rice contains high levels of one of the vitamin E compounds known as "gamma-tocotrienol" as well as "gamma-oryzanol" antioxidants.
Many studies have shown that these antioxidants can reduce blood levels of LDL "bad" cholesterol and may fight heart disease.
So black rice bran may be even healthier than brown rice, Xu says.
He and his colleagues also showed that pigments in black rice bran extracts can produce a variety of colors, from pink to black, and may be a healthier alternative to artificial food colorants that manufacturers now add to some foods and beverages.
He writes that several studies have linked some artificial colorants to cancer, behavioral problems in children, and other adverse health effects.
Currently, black rice is used mainly in Asia for food decoration, noodles, sushi, and pudding, and Xu says that he would like to see it eaten by more Americans.
Black rice bran could be used to boost the health value of foods, such as snacks, cakes, and breakfast cereals, Xu and his colleagues suggest.
This study was presented at a medical conference in Boston. The findings should be considered preliminary because they have not yet undergone the "peer review" process, in which outside experts scrutinize the data prior to publication in a medical journal.
SOURCES:
News release, American Chemical Society.
2010 National Meeting of the American Chemical Society, Boston, Aug. 22-26, 2010.

Pay Growing Faster for Nurse Practitioners Than Physicians

August 25, 2010 — In a sign of their value in a shorthanded clinical workforce, nurse practitioners (NPs) in group practices saw their compensation increase 4.9% last year, outpacing physicians as a whole, according to the Medical Group Management Association (MGMA).
Compensation for primary care physicians rose 2.9% in 2009, the MGMA reports in its latest Physician Compensation and Production Survey: 2010 Report Based on 2009 Data. Specialists took a 4.1% pay cut, although some individual specialties such as dermatology (12.3%) and ophthalmology (7.7%) posted sizable gains.
At $85,706, the median compensation for NPs in 2009 was far less than what primary care and specialist physicians earned — $191,401 and $325,916, respectively — in group practices. Still, NPs are slowly gaining ground. Since 2005, their compensation has risen 21.9% compared with 13.9% for primary care physicians and 2.9% for their specialty counterparts, according to the MGMA.
"We're in demand," said NP Jan Towers, PhD, director of health policy for the American Academy of Nurse Practitioners, about the compensation trend. "NPs don't have any problems getting work."
The job market is so good that it has been able to absorb a tidal wave of new NPs. The ranks of the profession have grown from 82,000 NPs in 2000 to 140,000 today, according to Dr. Towers.
At the same time, Dr. Towers told Medscape Medical News, a 4.9% pay raise in 2009 is not spectacular. "We should be getting more of an increase," she said.
Physician assistants (PAs) are not far behind NPs in their earnings trajectory. Compensation has risen 17.8% for PAs in primary care and 19.8% for those in surgical specialties since 2005. PA pay hikes in 2009 were less impressive, however, at 1.8% and 0.3%, respectively.
NPs Generate More Revenue Relative to Compensation Than Physicians
The current shortage of primary care physicians is creating higher demand for NPs, which in turn increases their compensation, said Justin Chamblee, a consultant with the Coker Group, a practice management consulting firm in Atlanta, Georgia.
By all accounts, this demand promises to grow stronger under healthcare reform, which will extend insurance coverage to 32 million additional individuals through 2019. Healthcare reformers view both NPs and PAs as an economical way to help tend to these newly insured individuals. Licensed to diagnose illness and prescribe medications, NPs, along with PAs, can perform about 80% of the services provided by primary care physicians, with comparable quality, according to a number of published studies.
Dave Duncan, a senior search consultant with the healthcare recruitment firm Cejka Search in St. Louis, Missouri, said medical practices hire NPs to relieve overworked physicians, share call duty, and staff rural clinics. "But it's getting tougher to find these folks," Duncan told Medscape Medical News. One reason is the growing number of retail clinics operated by drug stores, big-box retailers, and health systems, which also hire NPs to treat patients.
NPs can boost the bottom line of a medical practice in several ways, experts say. By assigning simpler medical cases to NPs, physicians can concentrate on the more complex ones, which insurers reimburse at higher rates.
At the same time, a primary care medical practice that traditionally would hire extra physicians to help carry a burgeoning patient workload can get more bang for its buck hiring NPs instead, based on the ratio of compensation to collections — that is, revenue — for the 2 professions. General internists, for example, received a median $197,080 in compensation last year while generating $366,622 in collections, according to the MGMA. In contrast, the ratio of compensation to collections is better for an NP in primary care, at $84,488 to $228,668. Put another way, 2 such NPs would generate more revenue than a single internist, but their combined compensation would be less than the internist's. The same math also works in favor of PAs.

Physicians' Religious Beliefs Influence End-of-Life Decisions

August 26, 2010 — Physicians who describe themselves as nonreligious are almost twice as likely to make decisions that may end a patient's life compared with physicians who described themselves as religious, according to new research.
Clive Seale, PhD, from Barts and the London School of Medicine and Dentistry, in the United Kingdom, reported the findings online August 26 in the Journal of Medical Ethics.
"The relationship of UK doctors' religiosity and ethnicity to actual end-of-life decisions is poorly understood," noted Dr. Seale in his report. "The present study reports findings on these from a nationally representative survey of doctors, using methods that allow for comparison with censuses and surveys of the general UK population."
A total of 8857 UK medical practitioners were mailed an anonymous questionnaire to assess their end-of-life decisions for patients. Of those, 3733 (42.1%) responded, and 2923 reported on the care of a patient who had died. Specialties included were weighted for those in which end-of-life decisions are more common, such as neurology, elderly care, palliative care, intensive care, and general practice.
Physicians who described themselves as "extremely" or "very non-religious" were almost twice as likely to report having taken the kinds of decisions expected or partly intended to end life as were those with a religious belief.
Ethnicity was not related to rates of reporting ethically controversial decisions, although it was related to support for assisted dying/euthanasia legislation. Specialty was strongly related to whether a physician reported having taken decisions expected or partly intended to end life. Physicians in hospital specialties were almost 10 times as likely to report this as palliative care specialists.
The most religious physicians were also significantly less likely to have discussed end-of-life care decisions with their patients than other physicians.
Specialists in the care of the elderly were more likely to be Hindu or Muslim, whereas palliative care physicians were more likely than other physicians to be Christian and white and to state that they were "religious." Overall, white physicians, who were the largest ethnic group, were the least likely to report strong religious beliefs.
These attitudes were reflected in support for assisted dying/euthanasia legislation, with palliative care specialists and those with a strong faith more strongly opposed to euthanasia. Asian and white physicians were less opposed to such legislation than physicians from other ethnic groups.
"Whether religious or non-religious, it would seem advisable that doctors become more aware of how broader sets of values, such as those associated with religiosity or a non-religious outlook, may enter into their decision-making in end-of-life care," Dr. Seale concludes.
The study was supported by the National Council for Palliative Care. The author has disclosed no relevant financial relationships.
J Med Ethics. Published online August 26. 2010.

Headache in Teens Related to Lack of Exercise, Weight Gain, Smoking

August 19, 2010 — Teenagers who get little exercise, are overweight, or who smoke are more likely to have frequent headaches or migraines, report researchers.
"There was a significant trend for stronger associations between the number of negative lifestyle factors that were present and the different headache diagnoses and headache frequency," point out the investigators led by John-Anker Zwart, MD, from Oslo University in Norway. "We believe that the associations observed and the additive effect of these negative lifestyle factors on the prevalence of recurrent headache strongly indicates that these lifestyle factors are possible targets for headache preventive measures."
The new study appears in the August 18 issue of Neurology. As part of the cross-sectional study, researchers interviewed more than 5500 students about headache complaints. The adolescents also completed a questionnaire and underwent a clinical examination with height and weight measurements.
Investigators classified adolescents who were very physically fit and who were not current smokers as having a good lifestyle. Negative lifestyle factors were surprisingly common with low physical activity in 31%, smoking in 19%, and overweight in 16% of these teens.
In adjusted multivariate analyses, recurrent headache was associated with overweight (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.2 – 1.6; P < .0001), low physical activity (OR, 1.2; 95% CI, 1.1 – 1.4; P = .002), and smoking (OR, 1.5; 95% CI, 1.3 – 1.7; P < .0001). The presence of more than 1 negative lifestyle factor heightened the risk of headache.
Table 1. Prevalence Odds Ratios for Headache Diagnoses

Lifestyle	Total (n = 5588)	Recurrent (n = 1601)	Migraine (n = 392)	Tension Type (n = 950)	Nonclassifiable (n = 259)
Good	2856	1.0	1.0	1.0	1.0
Intermediate	1920	1.3	1.5	1.2	1.3
Poor	717	1.8	2.1	1.6	1.8
Very poor	95	3.4	3.7	2.8	5.0
P value	–	<.0001	<.0001	<.0001	<.0001

Table 2. Headache Frequency in Relation to Lifestyle

Lifestyle	Total (n = 5529)	Less Than Monthly (n = 306)	Monthly (n = 790)	Weekly or Daily (n = 446)
Good	2827	1.0	1.0	1.0
Intermediate	1897	1.0	1.3	1.3
Poor	712	1.4	1.9	2.0
Very poor	93	1.2	3.7	5.0
P value	–	.103	<.0001	<.0001

This study shows overweight, low physical activity, and smoking are independently and in combination associated with recurrent headache among adolescents, report the study authors.
In an accompanying editorial, Dr. Andrew Hershey and Dr. Richard Lipton say that "this study is a vital step toward a better understanding of lifestyle effects and the potential for behavioral interventions for adolescents with headache disorders."
Dr. Hershey is at the University of Cincinnati in Ohio and Dr. Lipton is at the Albert Einstein College of Medicine in the Bronx, New York. They point out the effects of each negative lifestyle factor were similar in magnitude for each headache type. "This lack of specificity for headache type raises the possibility that these factors may be associated not just with headache but with all-cause pain."
These results mirror those of another study published in June in the journal Headache. Investigators led by Rudiger von Kries, MD, from Ludwig-Maximilians-University in Munich, Germany, found that being physically active and abstaining from alcohol, caffeine, and tobacco could help prevent headaches in adolescents.
The study included 1260 students, and after controlling for socioeconomic variables, the prevalence of any headache was increased in teens who reported regularly drinking cocktails (OR, 2.0; 95% CI, 1.3 – 3.0), who drank at least 1 cup of coffee per day (OR, 2.0; 95% CI, 1.2 – 3.5), and who were physically less active (OR, 2.0; 95% CI, 1.3 – 3.1). Smoking daily had an OR of 1.8.
These findings, say editorialists, suggest that a better understanding of modifiable risk factors and trigger factors may lead to novel intervention strategies.
Study coauthor Dr. Stovner has received financial support from BTG, Minster Pharmaceuticals, Pfizer, GlaxoSmithKline, Merck, AstraZeneca, Allergan, Nycomed, Desitin Pharmaceuticals, GmbH, and EMD Serono. Dr. Stovner has also served as an expert legal witness for Oslo Tingrett. Dr. Holmen receives research support from the Norwegian Research Council.
Neurology. 2010;75:712-717.

H1N1 Influenza Pandemic Is Over, WHO Declares

August 10, 2010 — The controversial H1N1 influenza pandemic is officially over, the World Health Organization (WHO) declared today.
"We are now moving into the postpandemic period," said WHO Director-General Margaret Chan, MD. "The new H1N1 virus has largely run its course."
The 2009 H1N1 influenza virus has not disappeared, Dr. Chan noted, and it still poses a risk for serious illness, especially for young children, pregnant women, and persons with respiratory or chronic illnesses. However, the agency expects the virus to circulate and behave as one of several seasonal varieties in years to come, and not to dominate the pack.
"Many countries are reporting a mix of influenza viruses, again as is typically seen during seasonal epidemics," said Dr. Chan.
On June 11, 2009, WHO declared that transmission of the novel influenza virus had morphed into a full-blown pandemic, which is level 6 on a scale that the agency uses to classify influenza outbreaks. The postpandemic phase, which is at the end of the scale, indicates that influenza activity is at seasonal levels.
Earlier today, an emergency committee that advises Dr. Chan on the pandemic convened by teleconference and concluded that "the world was no longer experiencing an influenza pandemic, but that some countries continue to experience significant H1N1 (2009) epidemics," according to WHO.
During the spring and summer, virus transmission has dramatically tapered off in the Northern Hemisphere. WHO said on Tuesday that it had delayed making a decision on whether the pandemic was over until the emergency committee could assess the virus' behavior in the southern hemisphere during its winter influenza season. The committee concluded that for both hemispheres, 2009 H1N1 virus activity "no longer represented an extraordinary event requiring immediate emergency actions on an international scale."
Pandemic Less Deadly Than Feared Because of Hard Work, Good Luck
WHO has been accused in some quarters of declaring a "fake" pandemic, given that the H1N1 virus has killed fewer people than seasonal flu viruses on an annual basis in countries such as the United States. The agency has denied intentionally exaggerating the pandemic's severity for ulterior motives, such as boosting sales for vaccine manufacturers. Nevertheless, Dr. Chan said today that the pandemic "has turned out to be much more fortunate than what we feared a little over a year ago."
Dr. Chan attributed the fortunate outcome in the pandemic saga to a combination of hard work and "pure good luck."
"The virus did not mutate during the pandemic to a more lethal form," she said. "Widespread resistance to oseltamivir [Tamiflu; Roche Inc] did not develop. The vaccine proved to be a good match with circulating viruses and showed an excellent safety profile."
On another positive note, Dr. Chan said that infection rates of 20% to 40% in some areas have created a level of protective immunity, augmented by good vaccination coverage in many countries.
However, public health authorities should continue to remain vigilant about the 2009 H1N1 virus instead of letting down their guard, she said. For one thing, a small proportion of pandemic influenza patients — including young, healthy ones — experienced a severe form of primary viral pneumonia that was very hard to treat. Dr. Chan said nobody knows whether this pattern will continue during the postpandemic phase.
In addition, WHO expects the virus to change as a result of antigenic drift, lowering the protection offered by the community-wide immunity that has developed so far. At the same time, significant influenza outbreaks could occur in areas that got off lightly during the pandemic.
The WHO prescription for the postpandemic era mirrors its advice during the pandemic itself:

• Clinicians should vaccinate individuals against the 2009 H1N1 virus with either a monovalent vaccine or a trivalent seasonal vaccine that contains a strain of the pandemic virus (the United States will use the latter this fall).
• Good personal hygiene is still in order — clinicians should advise their patients to continue to cover their mouths when they sneeze or cough and to diligently wash their hands.
• As during the pandemic, patients who have a severe or deteriorating case of influenza should be treated with oseltamivir immediately, and clinicians should prescribe either oseltamivir or zanamivir (Relenza; GlaxoSmithKline) as soon as possible for patients who are higher risk for severe or complicated influenza.

ACIP Updates Guidelines for Prevention and Control of Influenza With Vaccines

August 3, 2010 — The US Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) has issued new 2010 recommendations for prevention and control of influenza with vaccines, according to guidelines reported early release in the July 29 issue of Morbidity and Mortality Weekly Report. This report updates the 2009 ACIP recommendations concerning the use of influenza vaccine for influenza prevention and control.
The report also describes a US Food and Drug Administration labeling change for Afluria (CSL Biotherapies) influenza virus vaccine to reflect the risk for fever and febrile seizure.
"Influenza A subtypes that are generated by a major genetic reassortment (i.e., antigenic shift) or that are substantially different from viruses that have caused infections over the previous several decades have the potential to cause a pandemic," write Anthony E. Fiore, MD, from the Influenza Division, National Center for Immunization and Respiratory Diseases, CDC, Atlanta, Georgia, and colleagues.
"In April 2009, a novel influenza A (H1N1) virus, 2009 influenza A (H1N1), that is similar to but genetically and antigenically distinct from influenza A (H1N1) viruses previously identified in swine, was determined to be the cause of respiratory illnesses that spread across North America and were identified in many areas of the world by May 2009. Influenza morbidity caused by 2009 pandemic influenza A (H1N1) remained above seasonal baselines throughout spring and summer 2009 and was the cause of the first pandemic since 1968."
Highlights of 2010 Guidelines
The 2010 guidelines emphasize the following:

• All persons at least 6 months old should receive annual vaccination for the 2010-2011 influenza season;
• During the 2010-2011 season, 2 doses of a 2010-2011 seasonal influenza vaccine should be given at a minimal interval of 4 weeks to children aged 6 months to 8 years with unknown vaccination status who have never received seasonal influenza vaccine before (or who received seasonal vaccine for the first time in 2009-2010 but received only 1 dose in their first year of vaccination), as well as to children who did not receive at least 1 dose of an influenza A (H1N1) 2009 monovalent vaccine regardless of previous influenza vaccine history;
• Vaccines should contain the 2010-2011 trivalent vaccine virus strains A/California/7/2009 (H1N1)-like (the same strain as was used for 2009 H1N1 monovalent vaccines), A/Perth/16/2009 (H3N2)-like, and B/Brisbane/60/2008-like antigens;
• The report describes Fluzone High-Dose (sanofi pasteur), a newly approved vaccine for persons at least 65 years old; and
• The report also provides information about other newly approved, standard-dose influenza vaccines and expanded age indications for previously approved vaccines.

The updated guidelines recommend starting vaccination efforts as soon as the 2010-2011 seasonal influenza vaccine is available and continuing throughout the influenza season, and they also provide a summary of safety data for US-licensed influenza vaccines. During the 2010-2011 influenza season, vaccination and healthcare providers should check CDC's influenza Web site for any updates or supplements that might be needed to these recommendations, as well as for recommendations for influenza diagnosis and antiviral use published before the start of the 2010-2011 influenza season.
Recommendations for 2010
A summary of recommendations for influenza vaccination for 2010 is as follows:

• Annual vaccination is recommended for all persons aged 6 months or older.
• As providers and programs make the transition to routine vaccination of all persons aged 6 months or older, a focus of vaccination efforts should continue to be protection of persons at higher risk for influenza-related complications.
• When vaccine supply is limited, vaccination efforts should prioritize persons who:   
  • Are aged 6 to 59 months or at least 50 years;
  • Have chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, neurologic, hematologic, or metabolic disorders (including diabetes mellitus);
  • Have disorders of immunosuppression, including those caused by medications or by HIV);
  • Are or will be pregnant during the influenza season;
  • Might be at risk for Reye's syndrome after influenza virus infection because they are aged 6 months to 18 years and are receiving long-term aspirin therapy;
  • Are residents of nursing homes and other long-term care facilities; American Indians/Alaska Natives; morbidly obese (body mass index ≥ 40 kg/m²); and/or healthcare personnel;
  • Are household contacts and caregivers of persons with medical conditions putting them at greater risk for severe complications from influenza, or of children younger than 5 years and adults 50 years or older. The guidelines particularly emphasize vaccinating contacts of children younger than 6 months.

"Emphasis on providing routine vaccination annually to certain groups at higher risk for influenza infection or complications is advised, including all children aged 6 months–18 years, all persons aged ≥50 years, and other persons at risk for medical complications from influenza," the authors of the report write. "Despite a recommendation for vaccination for approximately 85% of the U.S. population over the past two seasons, <50% of the U.S. population received a seasonal influenza vaccination in 2008–09 or 2009–10. Estimated vaccine coverage for the 2009 H1N1 monovalent vaccine coverage was <40%."
MMWR Morb Mortal Wkly Rep. July 29, 2010;59(Early Release);1-62.